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.
- 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.
- 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.
- 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.
- 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?
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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.