11 June 2008

Advice for new EM grads

It's that time of year again. New interns will be flooding the wards, and newly minted attendings will be starting their first "real jobs," for some the first "real" job they have ever held.* So I'd like to play Polonius and offer some unsolicited words of advice for all those brand-new Emergency Physicians heading out to their first staff positions.

  1. Make a good first impression. This is critical. Your new partners will form an opinion of you based on their early experiences, and those first weeks on the job are crucial in establishing yourself as a "good hire." Show up on time; ten minutes early is better. Dress professionally; relaxed is OK in the ER, but a pressed white coat or a collared shirt looks better than rumbled scrubs. Smile a lot and even when things are frustrating, keep your temper in check. Remember that in most groups, this is a probationary period to see if you are a good fit for partnership. Put your best foot forward.
  2. Don't be scared. You know how to do this. "New Attending Syndrome" is inevitable, as you first shoulder the sole responsibility for patient care. But have confidence in your knowledge base and don't change your practice style just because there's no supervisor looking over your shoulder any more. If you would have sent the patient home as a resident, then do so as an attending. Once you start practicing scared, it's a hard habit to break.
  3. Learn the local politics. Make sure you know who the medical director is, who the nurse managers are, the medical staff chairs, and the administrators who exert influence over the ER. Are there any existing or recently-resolved conflicts? Any of your new partners who are disaffected? Any specialties or medical staff docs who hate the ER? Any financial disputes within the group? Don't take sides in any ongoing pissing matches if you can avoid it, but make it a point to survey the lay of the political landscape.
  4. Figure out the local standard of care. Every hospital handles stuff differently. Do they admit syncope? Is there a rapid chest pain protocol? Does your group write admitting orders? Who admits GI bleeds? How sick do you need to be to get into the ICU? Conscious sedation?
  5. Don't rock the boat (yet). If there are things in #4 that you don't like, you may not be in a position to effect change, especially until you have completed #3. Establish yourself as a reliable and productive doc before you start agitating for changes in procedures, especially on contentious turf-related issues.
  6. Make the nurses your allies. Emergency medicine is truly a team sport, and the nurses will make or break you. Learn the nurses' names, especially the charge nurses. Bring them food or coffee on the night shift. If they go out in the morning, see if you can come along. Do not flirt or date them if you are single (and especially not if you are married). A sexual harassment allegation is not the way to start your career. Respect their experience and their judgment, and they will save your ass many times.
  7. Get to know the medical staff. Go to medical staff meetings, and go up to the floor to follow up on admitted patients. Read the paper in the doctor's lounge. Show up to the department meetings for other specialties if they are open. They love it when a representative of the ER shows interest and respect by coming to 'their' meeting. Your middle-of-the-night phone calls will go over better if the consultants have seen your face and think well of you.
  8. Get up to speed. As a new doc, you will not be able to move the meat right out of the gate. But there will be a lot of people watching how you manage patient flow, and you do not want a reputation as a slow doc. Keep picking up patients right until the end of your shift and stay as long as you need to to get them dispo'd. Impress people with your work ethic. Pay attention to the number of patients you see daily, set yourself a goal, and track to see how you are performing. Trust me, your employer will be doing the same.
  9. Live within your means. Your income is about to increase by an order of magnitude -- don't go nuts. Buy a smaller house than you can afford, hold off on the BMW for a few years, and build up a cash balance first. You should have 60 to 90 days' liquid cash before you start spending and living large. Make sure you have life and disability insurance -- many residencies offer individual disability plans to graduating residents, and you should definitely sign up if you can. Pay off your credit cards. Start an investment account.
  10. Enjoy life. Most community ER docs work 12-15 shifts a month. That's a lot more time off than residents can comprehend. Reintroduce yourself to your spouse and family. Didn't you use to have hobbies? Go hiking, sailing, or, um, start a blog.
  11. Build a niche. What do you want to do with your career? There are lots of ways to be involved and to grow professionally. Sit on hospital specialty committees, or work in medical staff governance. Become involved in the administration of your group, or local EMS. Work on quality improvement projects in the ER. Learn about reimbursement or risk management. Get on an ACEP committee.
  12. Seek help when you need it. Don't embarrass yourself with avoidable errors; take advantage of whatever resources there are to help you out. If you work in double coverage, don't hesitate to ask your colleagues how things work as issues arise. They know how to navigate the local system and are usually happy to share the insider's knowledge. But your medical director won't be happy about cleaning up your messes, especially if you try to overcome obstacles through force of sheer will alone.
  13. Be forgiving of yourself. You are going to fuck up. It's certain. You're going to be too slow, you will put your foot in your mouth, you'll let yourself be browbeaten by an irate consultant, and you may even harm a patient. These things are part of the game and you can't completely avoid them. Don't get down on yourself when it happens, learn from your mistakes if you can, shake it off, and get back in the game.
A lot of these can be thought of as the voice of experience, or in the department of "do as I say, not as a do." If I were starting over, I'd do a lot of things differently. It's worked out pretty well for me, but had someone given me a similar list at this point in my training, things would probably have been a lot easier, and I'd probably have pissed off a lot fewer people in the process.

Hope this is helpful, and commenters should feel free to add on advice in the comments!

*which is not to say that med school and residency aren't work, just that they are steps towards the ultimate goal of becoming a practicing physician.


  1. goqeuGreat post! Seems to me that many of your points are equally informative as you become a more human being!

  2. Hope all future ER docs pay attention to this. ER docs are an integral part of society, one for which I am very grateful. A handful of ER docs and consultants once saved my life, and I'm glad that they proved to be outstanding ER docs. Everyone deserves that superior care.

  3. Awesome. I will save this in the file for three years from now. Any comparable advice for incoming EM interns? (I seem to remember some discussion of this in the past).

  4. Great advice. A lot of it applies to me as a newly graduated nurse as well.

  5. I love this post! One thing I would add for new ER docs: Treat the paramedics with respect. I've noticed a lot of new docs disregard them, even ignore them, but they are a valuable source of patient information. By the time you see the patient, the chief complaint might be resolved or close to it, but you need to know what happened. Or maybe the patient is still in bad shape and you need to know what has already been tried (and failed). They can quickly point you in the right direction and save you time, if you talk to them and they respect you. Like all professions, some are better than others, but if you know your stuff, you'll quickly figure out who is who.

  6. How about some "Advice for new EM Interns?"

  7. Quite a good list.

    I'd add that you might not want to uy a house in your new place right off the bat. Most EM grads change jobs within the first 2 years or so.

    I can testfy that buying and selling a house in 10 months is hard on the wallet.

    So, lease for a year, then buy.


  8. I think ER docs are known to the medical staff more by the quality and propriety of our medical care (and specifically our admissions) than by how friendly we are in the doctor's lounge.

    Make your strong impression by not admitting lame "soft" CYAs (especially after midnight) and by providing exceptional initial workup and therapy of the patients you DO admit.

    If you admit a bunch of BS, the docs are likely to interrogate you endlessly every time you call them. If you build a reputation as someone who admits appropriately, then you won't spend as much time on the phone over the rest of your career.

  9. I wish someone had given me ths advice when I was starting out.

    Thanks for a great post.

  10. Thanks, this is really helpful and practical!

  11. All of your advice is great, Doc. I only write to emphasize something that you wrote, "Make the nurses your allies." Everything you offer here is good advice. However, the emphasis should be on the final sentence: "Respect their experience and their judgment." We do not know as much as you do, and we know it. You have the position of authority, and we are O.K. with that. However, the senior members of the nursing staff have seen a lot. Maybe even a few things that you have not seen yet. Listen to us! Make your own decisions, of course, but hear us out. We have been trained to assess patients differently than you have, which sometimes leads to misunderstandings between us. However, the differences in our approaches to assessment mean that sometimes we notice things that are not elicited in the medical H&P. Now don't go getting defensive! I'm not trying to one-up you. I couldn't do that if I wanted to, and I don't want to! Just know that, even though we do not have anything close to your education, we do have an education, and not a completely bad one (albeit different from yours) and sometimes we make some good calls.

    Want the nurses to love you? It is so easy. Let us have a voice in the care of our patients. Not the same voice as a doctor, of course, but a voice. Buying the nurses food is a great idea, and we really enjoy having you with us when we go out after shift, but we are more interested in making a difference in our patient's lives than we are donuts. Treat us like the professionals we work so hard to be, and we will walk on burning coals for you!


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