Dear Director: As part of my New Year’s resolution, I want to focus on being a more successful emergency physician. But I’m a little stuck. How do you define success in emergency medicine, and how do I move in that direction?
Success can be defined in many ways. If you’re a senior resident searching for a job, getting a signing bonus may make you feel like your job search was successful. If you’re an experienced physician and administrator, having your clinical hours reduced to focus on administrative activities could be a sign of success. If you practice solid emergency medicine for your career, you’ll have about 100,000 patient encounters, and that alone could stand as a marker for a successful career.
I went into emergency medicine to save lives, but in reality, critical care is only a small percentage of what we do. Therefore, I’ve redefined how I value the patient encounter and what makes me feel good at the end the day. While intubating a tough airway or saving a life is awesome, engaging with a patient such that they ask you to be their PMD – or getting a high-five from a toddler on his way out – makes any shift feel pretty successful.
However, when I put on my chairman hat and have to evaluate other docs, I have no choice but to come up with more specific parameters for success. I need to know which docs are thriving, and which are not. To that end, I’ve come up with five pillars that I believe define success. Think about what qualities you want in the docs working next to you and what traits make you dread doing a double coverage shift with other docs. My list includes high productivity, being clinically sharp, having a high level of knowledge, achieving good patient satisfaction, and finally, maintaining balance and wellness in your personal life.
Work Smarter and More Efficiently
Most groups are under pressure to increase their productivity. Successful physicians are productive. They often work smarter and more efficiently than others. This involves maximizing the EMR, taking advantage of scribes (some docs even hire their own when their hospital or company won’t) and making decisions with best practices or evidence based guidelines. Highly productive physicians (measured as either RVUs/hour or patients/hour) seem to have another gear they can kick into to knock out a filled chart rack. More importantly, they typically understand the workings of ED flow and how to pace themselves during their shift – lots of patients the first two hours, re-bolus with patients midway through the shift, and be sure to pick up a patient or two in the last 30-60 minutes of the shift.
Bringing Your “A Game”
Do you ever wonder how your colleague makes the zebra diagnosis or why they get so many compliments? We’re human and we’re going to make mistakes, but you can increase your performance in the clinical arena in several ways. First, you must show up to work every day with your “A Game,” and that starts with attention to detail. It’s easy to not pay attention to medical reconciliation or not look at vital signs before discharging a patient, yet it’s amazing how many cases I review where attention to these details would have altered a patient’s outcome.
A study by Sklar et al (Annals Emerg Med 2007) looked at 387,344 ED visits over 10 years and found that there were 30.2 deaths/100,000 patients within seven days of discharge from the ED. Half of those deaths were unexpected and 2/3 of the unexpected deaths had a possible error. Using these statistics in my 65K visit ED, approximately six patients die each year due to an error within a week after discharge. That’s a big number, a high malpractice risk, and something we all should want to reduce.
Sklar points out four themes for the unanticipated deaths, but the biggest two in my mind are the atypical presentations of an unusual problem (we are more likely to make the diagnosis if we aren’t just going through the motions) and abnormal vital signs on discharge. In Sklar’s study, 83% of the unexpected deaths had tachycardia. If you want to up your clinical game, always review discharge vital signs, and then spend time considering the etiology of the abnormality. It’s likely that you’ll make an impact on reducing the number of patients who die after ED discharge.
Often, I review cases where the patient had a variety of symptoms, but the doc didn’t connect the dots to make the diagnosis. Take for instance, the chest pain that you’ve mentally admitted to the tele bed within 30 seconds of entering the room, but in whom the hospitalist fortunately notices hypoxia and tachycardia and “encourages” you to order a chest CT and get the results before they go upstairs. If you’re attentive to the details of the case, you can minimize this type of mistake occurring.
We’ve probably all worked with someone who had a behavior that sabotaged their goal. This can be as simple as wanting to increase productivity but regularly showing up late or spending too much time during a shift checking email. I used to work with a great doc who could lose an hour of his day every time he thought he had a drug-seeking patient. Whether it was checking online databases or calling other ERs to review oxycodone prescriptions, the department could be falling apart and he would be caught up in his investigation. Clinically excellent people are able to reflect on their behaviors and actions and recognize these hot buttons and then work to keep their minds in the moment, control these triggers, and keep their departments moving forward.
From a patient point of view, the ideal physician needs to be more than clinically excellent; they need to be caring and compassionate. Hospitals measure this through patient satisfaction scores. Whether you like it or not, it’s part of the package, and hospitals and chairman expect high performance. You can’t be a successful physician and not have high patient satisfaction.
There are several things you can do to improve your patient sat and most focus on communication with the patient. Start with the basics: wear professional attire, knock on the door, introduce yourself to everyone in the room, sit down, provide a comfort measure, and do not interrupt too quickly. From there, be sure to communicate all the work that goes on behind the scenes with the patient. Explain how the work up will proceed, your tentative differential diagnosis, and the results of the testing that was performed. If you’re not already doing follow-up phone calls, try calling a portion of your discharged patients. Patients love this. It only takes a minute or two per patient, and after you’ve asked them how they’re doing and if they’ve arranged follow up, you may find the rare patient where your call makes a significant difference in their outcome.
Finally, listen to the complaints. Although none of us like to admit it, there’s usually a kernel of truth in each one. I once had a mother respond to a phone survey that I was the “worst doctor in the world” for not giving her baby antibiotics for her fever. While my decision was medically appropriate, what I failed to do was communicate well with her. It was 1 AM, patients were in the hallways, and her English wasn’t good. I didn’t have time to get a translator so we had a quick conversation in the hallway. I could have done better and it only would have taken a few minutes. This required some self-reflection on my part, rather than just blowing off an exaggerated statement, and then incorporating the experience into my future practice.
Grow in Knowledge
I suspect that our ability to recall the minutiae we learned in residency decreases shortly after we take the oral boards. However, we continue to become better clinicians with time and experience. As attendings, we learn when problems arise and we learn from our colleagues. Hopefully, we’re able to look back on our own clinical cases or on Q/A data as another source of knowledge. In addition, whether it’s a lecture to our colleagues, medical students, nursing, or EMS, we can learn a lot when given the opportunity to teach. While we all mentor new hires, take advantage of “reverse mentoring” and learn what’s hot in residency education (trauma, sono, ID, anticoagulation) from your new docs. However, the best physicians also supplement this clinical experience with more formal continued education. You need to be sure you know how you learn best and then find a way to get your CME updates accordingly. It might be an annual review course, but it could just as easily be a commitment to monthly readings or listening to podcasts. Successful physicians stay up to date and know how they learn best.
Each year, consider your weaknesses (if you have any doubts, ask your chairman or the nursing staff) and make an effort to address those topics in some way. Personally, I go to ACEP each year, and go to a couple of other lecture type courses, do some online CME and reading, but I learn best from simulation courses, which I take every year or two.
As a chairman, I look for behavioral changes such as showing up late to shifts, arguments with staff, or changes in handwriting. These could be red flags that signify a personal issue at home or a substance abuse issue. Doctors are not immune to life’s challenges. The physician divorce rate and alcohol/drug abuse numbers mirror the general population (50% and 15% respectively).
Financial strain can impact wellness. New attendings sometimes become house poor and always seem to need extra shifts to pay their bills. Older attendings may still want extra shifts because of alimony payments or children’s college tuition. A hectic work schedule impacts sleep and adds to stress and burn out. At a very minimum, we should be blocking time for regular exercise, for health maintenance exams with our own doctors, and for hobbies. It is difficult to be compassionate or patient if you are not well yourself. The healthier you are as a person, the better you can serve your patients as a physician.
Habits to highlight
- Bring your “A Game”: Making your best effort will help you achieve higher productivity and clinical excellence. By bringing your “A Game,” you focus on work, work harder, make the zebra diagnosis, reduce malpractice risk, and get more patient compliments.
- Details Matter: Paying attention to detail is critical for EPs. Pay attention to vital signs. Being detail-oriented also helps reduce bad outcomes and makes you a better doctor in the clinical arena.
- Embrace Communication: Much of patient satisfaction is about patient communication. It doesn’t require much additional time to make sure that the patient’s questions are heard and they understand the diagnosis and plan. This improves patient satisfaction and may reduce bad outcomes.
- Continue to Learn: The best and most successful physicians have a plan for continuous learning. This plan should address your weaknesses and enhance your strengths. Find out which method works best for you, and take time each year to grow your knowledge.
- Take Care of Yourself: Health and wellness, along with balancing family, hobbies, and career, will allow you to focus on your patients when you’re at work and be the best physician you can be.
Great article, Dr Silverman! For me, 3 effective anti-burnout tactics have been to supplement my EM career include
2. Teaching, and
3. Practicing outside of a single ED.
I encourage fellow EPs to enrich a portion of their careers through charitable medical outreach programs or military Reservist duties.
A great article Michael, except for the part about searching on-line databases for drug seekers. I now limit my practice to Kentucky where such searches are required by law before administering or prescribing controlled substances. It has ended the pressure to prescribe controlled substances to improve patient satisfaction scores, a very pernicious part of emergency medicine practice. And there is now clinical evidence that the most “satisfied” patients have worse clinical outcomes.
Teach- EMTs, paramedics, nurses, PA’s, residents, the public. It is another waty to keep atop of the knowledge item and your students will reward you with appreciation.
Also keep all the letters of appreciation from patients and families; so you can read them when the malpractice letters arrive.
While this may not have been intentional, it’s disappointing to see personal wellness listed last. Personal wellness is the key to all the other things you cited. Being well rested and having a reasonable shift load is the key to being efficient, compassionate, communicating well, and being able to pay attention to detail. No one is going to “bring their ‘A’ game” if they are being overworked with shifts and have a group that does not value physician well being and treats them like worker bees. Granted this point was made, but it would have been better if it was made first. For a specialty with such a high burn out rate, there simply needs to be more attention placed on our personal health.
Obviously one’s “A” game is determined by what they think should be achieved themselves, in the context of what is expected of them. Doctors are lauded when the former exceeds the latter, but rarely if ever when it’s the other way around. I think the successful Emergentologist will be those who further the specialty in 2015. They will fight for fair, clearly applicable metrics and calculations for things such as Patient “Satisfaction” as well as seek to raise the bar for delivery of quality care whether it’s through evidence based practices or improving patient involvement and responsibility taking in their own health success. What it is not is adhering to rhetoric about what is “here to stay” because we all know that no matter what, things come and go repeatedly (just ask bretyllium).
Another useless self-serving parental article by Silverman, praising the Chair and kindly ‘berating’ the EP who works shifts to worker harder, perform follow-ups, spend your free time taking expensive CME courses, and bring your A-game. Great insight. I done bringing my C game.
The Chairman’s A-Game…..go to useless meetings, bootlick the bosses, and avoid working in the department, and continue to manage-up by being a ‘yes-man’
Well, I have a nice “dragon macro” that allows minimal interruption to review the narcotics records (pulls up the site, drops in my passwords and I’m in in 6 seconds). I’m not always a fan of all ACEP recommendations, but we are recommended to use these databases and we improve our care delivery when we use them objectively.
Can’t agree with Craig McMurty enough. Let’s all bring our “A game.” More Advice: Let’s all be smarter (nail thse Zebras!), faster, taller, better hair, better teeth, “Communicate better.”
Betting when Chairman Silverman does see a difficult patient/family on his occasional shift and can’t get resolution to make everyone happy, it’s because of them being totally unreasonable and not related him. When his docs hit a snag, they should have brought their “A game” and done a better job. We all know this Chairman…Any more of this drivel of self serving irony and the article would be better served on GomerBlog. At least there it’s meant to be funny.
Come on Silverstein, you want us to donate our hard earned money to a foundation only to see negative results. These hospitals run plenty of money and skim off of the top. Hospits don’t need our pennies. I’m sure Silverstein is looked well upon by the Sr.VPs if every er doc donates—he’ll get credit/promotion and raise. Then after donating leave your ‘C’ game at home and bring only your ‘A’ game and that will not be enough. Silverstein will look at your handwriting and determine if you are a drug abuser. And do not forget to dress profession.make follow up calls. How bout an article from a director that is in tune with the doc sand who doesnot have a hidden selfpromotinhagenda
Just what I was hoping to read after another shift of 3.2 pts/hr! It may be a little late for a New Year Resolution but here goes: In 2015, I pledge to dress more professionally, sit down, spend at least 15 min per pt in the room, and……..wait a minute! How the heck can I see 3.2pts/hr and not lose income / productivity while fulfilling this redunculous resolution?!?
This article reminds me of the “Everything you need to know you learned in kindergarten” series.
I think I’ll just go back to trying to meet unrealistic patient expectations put forth by zealous advertising generated by our hospital system, answering internet derived patient concerns which are beyond being off-based in relation to their simple URI, sedating druken and pseudo-suicidal “customers”, and staving off the cafeteria or break-room culinary temptations to drop those 5lbs that I’ve been resolving every Jan 1 for the past 15 years!
Kudos to Dr.Silverman! He hit this one outta-tha-park! If you can’t bring your “A” game then go home and catch up on R&R. The 5 “Habits to Highlight” should be displayed in every ED staffroom and on the door of the residency director. This is the kind of stuff that makes an ED Director pure gold. Try it – and you’ll see the benefits on every shift for the rest of your career. For any of those doubting (as in many of the posts / comments I’ve read), I suggest that you just give it a try. You too will see that this stuff “drinks like water” and will quench your professional thirsts!
Dr. Stoddard just hit it out ov the park and into the cheap seats. I bring my A+ game every shift. Some days I may decide to bring my B or C game, but I just end up bringing my A or A+ game instead. Past 9 months I’m seeing 25% more/shift, yet pay is 2% more and dept coverage is stagnant. Five of us plan leaving. ED jobs are dysfunctional. Silverman should reply to the comments.
I always find the zebras, but thats after I wear professional attire, knock on the door, introduce myself to everyone in the room, sit down on a chair that was just occupied by a c. diff patient, provide a comfort measure (chicken and waffles and custard – a true hit in the ER), and never do I interrupt while they are textig/snapchatting on their smartphone. My secret on the Zebra Diagnosis…..my workup is shotgunned (Labs, CTs, MRI’s, U/S on everyone) and all are admitted. My awesome chairman has no clue.