Newsletters

POSTED: March 12th, 2019
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, January/February 2019,

By: Abby Cosgrove, MD

My very first patient as a new attending had a traumatic tension pneumothorax. I was the only physician in the entire hospital at that time.

Here goes nothing, I thought, as I frantically searched the supply room for a chest tube kit.During that same week a patient complaining of sudden onset severe back pain coded mid-sentence. Ultrasound showed a pericardial effusion.  

Here goes nothing, I gulped, spinal needle in hand.

Like many things in medicine, the first six months of attending-hood were an emotional roller coaster, filled with the highest of highs and the lowest of lows. There were days when I felt like I was easily moving patients through the department, practicing evidence-based medicine, connecting with people, and nailing procedures. Then, there were the days when I wondered if I should be practicing medicine at all.

It was easy to feel on top of the world at the end of residency. I had received incredible training, had served in supervisory roles, and had fine-tuned my leadership skills. I felt confident in my ability to care for patients and looked forward to the days of complete autonomy. I may have even felt… dare I say… bored.

Yet somehow when the clock struck midnight on July 1^st, the golden chariot I had been riding on turned into a gourd. I felt like an intern all over again. No longer hidden under the veil of “trainee”, my greatest weaknesses were revealed, and, even if to no one but myself, often left me feeling vulnerable and exposed. The good news is that in learning from countless mistakes, I was able to more clearly see the type of physician I had become, and the type of physician I still aspired to be.

I have always looked towards friends, mentors, and colleagues for advice, hoping to learn from their experiences and to seek guidance through the successes and failures of my own personal and professional life. I have been fortunate enough to have had an amazing support network along the way.

So, without further ado, it’s time to pay it forward.

To all of the third and fourth year residents graduating this spring, a few lessons I have learned in my first six months as an attending:

1. Lay eyes on every patient that is signed out to you.

Bad things happen to patients who are forgotten. If the patient has been signed out to you, they are now under your care. Laying eyes on a patient after sign-out will alert you to changes in clinical course, allow you to pick up on features of a physical exam that may have missed at the end of a busy shift, and makes the patient to feel that they are receiving the best care possible.

2. If you think about it, do it.

If you notice that you are trying to talk yourself out of doing a procedure (eg. lumbar puncture), know that you should probably be doing it. If you decide against it, make sure to document your reason why.

3. Don’t rely on consultants to make disposition decisions for you.

Not to state the obvious, but consultants on the phone cannot physically see the patient. As a new graduate, you may sometimes doubt your own diagnostic accuracy, treatment plan, or study interpretation. Recognize and accept the limits of your clinical knowledge, but never question your instinct.

4. Read all documentation written by advanced practice providers, RNs, and scribes.

 A defense argument of “I didn’t see it in the chart” will not hold up in court. It is amazing what you can miss when not being meticulous.

5. Never trust a patient with a chief complaint of constipation.

Beware of premature closure, especially for a “low risk” complaint that may have resulted in inappropriate triage. Little old ladies love to hide abdominal catastrophes.

6. Learn from your mistakes, and move on.

We all make mistakes.  Recognize and learn from them, but do not agonize over them. Do not forget to give yourself credit for the things you do well. 

7. Get your finances in order.

Residency’s primary focus is and should be about competency in emergency medicine. However, financial discipline early on will be one of your greatest weapons against burnout when you find that you are working because you want to, and not because you have to. Take the time now to develop a solid financial plan.

8. Have a person.

Whether it be your spouse, a friend, a colleague, or a mentor from residency, have a person you know you can call driving home after the worst shift of your life, and after the best. You will need the support, hugs, laughter, and mimosas now more than ever.

9. Develop a plan for lifelong learning, and stay involved.

You don’t need to know everything, but you do need to know where to find it. Whether you prefer to keep up-to-date by listening to podcasts, attending conferences, or reading journals, develop a routine to ensure lifelong learning.  Strongly consider remaining engaged in professional medical organizations as a way to feel connected to the larger emergency medicine community.

10. Treat every patient as if they were your family member.

It is easy to lose empathy after long stretches of shifts, which can lead to significant dissatisfaction and burnout. I recommend finding one patient (just one!) each shift with whom you can connect. Remember that every patient has an entire life story, just like your own.

While the transition between resident and attending can be challenging, I truly believe that it can be one of the most memorable and exciting times in your career. You will grow in ways you never imagined.  And when it’s finally time for your first solo intubation, remember…

Here goes nothing.  You got this!