Advice for new attendings from attendings

[beyond all hope]

I know this is a pretty broad question for you attendings out there, but I'm going to ask it anyway.

I'm going to be starting as an academic attending in July. Basically I'm looking for advice so I won't make the 'rookie' mistakes I'm expecting to make in my first few years out.

1) What were your biggest challenges as a new attending?

2) What were the biggest mistakes you made?

3) What would you differently in your first year of being an attending, if you could?

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[spyderdoc]

1) What were your biggest challenges as a new attending?

I think the biggest challenge was getting used to the idea that I was making the final decisions without having to present the patient. You will find yourself thinking twice about your dispos (should I really let that 18yo w/ CP go home?) and diagnoses.

It is very appropriate to ask yor fellow attendings for help looking at a film or figuring out what to do w/ a patient. For example, at Kaiser, all GI bleeds got admitted to IM, and the GI followed as a consultant. At my new job, which is a fee for service environment, a lot of the GI docs admit the GI bleeds to their own service. It takes a good solid month to figure out all this BS stuff. You will be asking your colleagues and clerks for a lot of help to figure out the basic logistics of your new hospital.

It is NOT appropriate to make a habit of "running patients" by your colleagues. Of course it is ok to do if you are truly stuck on something, but if you make a habit of it, you may be taken as a PITA guy w/ no confidence in how you handle patients.

Remember that the RNs will save you ass on a routine basis, make sure to be as nice to them as you can without letting them take advantage of you. For example, bring bagels on an occasioinal weekend morning, and they will love you. Don't bring them everyday, or they will EXPECT them. You don't want them to be "upset" with you on the day you are running late and can't stop by and get bagels.

Since you are going to a teaching institution, you will have to get used to stepping aside and letting the interns and residents get first and second dibs on procedures. You will be third in line to get the airway. Make sure you are damn good at getting difficult airways, because they may be the only ones you are going to be doing as an academic attending.

You are going to have to get used to interns and residents coming to you at all times from all angles to present patients. I am not in academics, so I can't really help you out too much there, but you will have to find your groove in knowing all the patients better than the housestaff does.

2) What were the biggest mistakes you made?

Taking and believing the previous guy's signouts. When you take a signout, listen to the guy, then go in and see the patient as if you are starting over. Take a few minutes and get yourr own history and do your own physical. Signouts can really get you into trouble. For example "Oh, that 90 yo guy fell, and has back pain. Check his LS spine xray, then he can go home", can very well turn into a syncopal episode due to a rupturing AAA causing his back pain.....

You are the best advocate for your patient. If you really feel that the patient should be admitted, push the issue w/ the consultant, and don't let them bully you into sending them home.

I'm sure there are others, but I gotta take off. I will post more alter if I think of anything else. You will do well. You are well trained, and will find that stepping into your new role will just come to you quicker and easier than you think!
Good luck

 

[Apollyon]

It is very appropriate to ask yor fellow attendings for help looking at a film or figuring out what to do w/ a patient.

It is NOT appropriate to make a habit of "running patients" by your colleagues. Of course it is ok to do if you are truly stuck on something, but if you make a habit of it, you may be taken as a PITA guy w/ no confidence in how you handle patients.

It takes a good solid month to figure out all this BS stuff. You will be asking your colleagues and clerks for a lot of help to figure out the basic logistics of your new hospital.

This is solid, GREAT advice - at first blush, it may not seem all that different, but it is. What you want to be is the guy like everyone else - generally good, and a sniper on a few topics. That puts you on even footing with your colleagues, who are snipers on other topics. As such, when you manage your own patients, they move, and, when your special topic is at hand, you do it deftly and smoothly, which people notice. Then, when you have a question, it's peer-to-peer, colleague-to-colleague - not junior-to-senior, as if you're still a resident stuff. What you don't realize at first that, if it's a true conundrum to you, it will be to your colleagues also, and that's when more brains is better than fewer. We've had a few EKG's with 3 EM attendings and 3 senior residents go around and around with this and that, and it's collegial.

The logistics is another thing, and stuff that you weren't exposed to as a resident will come up, and the best way to not look like the PITA know-nothing guy is to delineate your plan (in one line) when you ask your colleague, until you get the hang of it - it's "GI bleeds with blood going - here, do they all go to the unit, or can they go to the floor"; it's not "where do I dispo a GI bleeder?", or "On the weekend here, who is better to call for a leaking TAA - thoracic or vascular?" instead of "Oh my God, this guy has a TAA, and I think it's bleeding!". Once you go around the horn, then these questions fall off.

I'm noted in my department for knowing who is on for what and how to finesse things like plastics vs ortho for hand (although there's dictated coverage daily) or plastics vs ENT for CMF (same deal with schedule), and VIR vs GI, or "when this guy is on, don't call his service" (not punitively, but because you won't get the result you need). There's always someone who is "that person", and, whether it's a colleague or a clerk, don't reinvent the wheel, and bide your time until that wheel is on your chariot and you're kicking ass.

Taking and believing the previous guy's signouts. When you take a signout, listen to the guy, then go in and see the patient as if you are starting over. Take a few minutes and get your own history and do your own physical. Signouts can really get you into trouble.

As one of our "pseudo-new" (did another residency and worked in the ED, then did EM) says, "I don't mean it offensively, but, just after signout, this is my time to fix all the mistakes you've made".


All in all, a wonderful post from spyderdoc.

 

[bartleby]

Good advice from both of the above posters. Particularly the bit about being super nice to all of the nurses and ancillary staff. It is natural for them to probe you a bit to test the waters, but if they get even a hint of the fact that you're a jerk or your condescending, don't get surprised when your lunch keeps getting "accidentally" thrown out every time somebody cleans out the fridge in the break room. A couple of other points:

As unplesant as it is to acknowledge, there are some residents/'terns who are going to need little to minimal handholding from you, while you will quickly realize that precepting troublemakers can easily be twice as painful as just seeing the patient on your own. Till you gauge your own comfort level and get to see the residents, expect presentations earlier in the management and physically lay hands & eyes on the patient sooner, rather than later.

When you walk into a room with a resident doing a procedure, force your hands into your pockets. Sure, you can do the procedure on the first attempt 99% of the time with your eyes closed in half the time...but that's how it's supposed to be... you're the attending now! Residents need to make their own mistakes in order to learn. Your job is to make sure that they don't hurt their patients in the process.

Yes, the ED will be hectic, and there will be plenty of times when you will not have time to teach during the shift, but this is no excuse. Take the resident aside for a minute and say something like, "Great job with that tube, but next time, why don't you try...".

Be an active listener during signout, as bad signout lies in the hands of the receiver as well as the giver. You'll learn quickly who you need to watch out for in this regard, but if you're not getting a good feeling for the plan (or if there is no plan at all), say, "So do you think that this 90 y/o woman will belly pain and a white count of 19K is going to be able to go home?" Then hopefully, they'll get more on point and say "well, I just heard her belly CT is negative and surgery doesn't want her." Then you can say something like, "Great... do you mind running her by the hopsitalist before you split since you know her so well?" Try to get a feeling for those who are "admitted and done" versus "uhhh....." If you get vague or wifty signout, make it a priority to give these people a bit of a onceover. A huge red flasg should be when a nurse approaches you and says, "I know Dr Smith told the resident to write up discharge instructions, but..."

Most importantly, HAVE FUN!

 

[beyond all hope]

Thanks for all the responses

Can't wait for July

 

[bulgethetwine]

Thanks for all the responses

Can't wait for July

Man, I'm surprised we didn't get MORE responses! I thought more ex-residents would be lurking out there...

 

[docB]

I actually was intending to reply to this but I got busy and it got buried for a while. My experience was as a private attending which is significantly different than that of an academic attending. Academic attendings have as a huge part of their duties resident and student education which I don’t do (we will start getting FP and IM residents in July and we’ve had a few students for a year). They also usually have research commitments which I don’t. Academics usually don’t have to worry about insurance issues and the admitting difficulties that they present although that is variable.

From a general standpoint I agree with what Spyderdoc said. It’s tough to get used to making your own decisions. It’s hard to become efficient in a new job AND a new system and hospital. The first year and a half was difficult. The consultants try to push you around and the nurses are still trying to figure you out. Once you get done with your break in period life gets much better.

One thing I will recommend is that after you get a chunk of the break in period under your belt you get involved in some kind of administrative activity. Get on a hospital committee, become a director of something like EMS, education, CQI (that’s a pretty easy one to get because it’s so thankless), or whatever. It’s good to learn how things work politically and you’ll get to know the players which really helps when situations arise. I hope that’s helpful.

 

[BKN]

I know this is a pretty broad question for you attendings out there, but I'm going to ask it anyway.

I'm going to be starting as an academic attending in July. Basically I'm looking for advice so I won't make the 'rookie' mistakes I'm expecting to make in my first few years out.

1) What were your biggest challenges as a new attending?

2) What were the biggest mistakes you made?

3) What would you differently in your first year of being an attending, if you could?

Mybad. I should have answered this too. I agree with all the clinical stuff that others have discussed, but maybe I should add academic and career advice.

Early in your academic career read the tenure and promotion policy and have a discussion with your chairman to explain it to you. Think about your hopes, desires and plans. Are you going to be a researcher type, a teacher type or a university service type? In fact all of us have more than one facet, but the tenure track guys (later to be called professor) pursue them all.

Decide if you want to pursue the tenure track. If so, you need to start thinking about a research program (which is bigger than a research question that can be answered in a single study). It should be something that will keep you busy for ten years.

Whichever goals you lay out for yourself, it's unlikely that you have all the tools you need just from residency.

You might need a fellowship, you might need bench training, you might need clinical research training. For the latter consider a masters in clinical investigation or MPH. Even better take the master's in clinical research design and statistical analysis offered by U. of Michigan SPH. It changed my career and freed me from the drudgery of dept administration. Well, at least for 7 years and then I took up being a PD again. That's a research stopper.

Consider short courses: ACEP teaching fellowship, ACEP Emergency Medicine Basic Research Skills (EMBRS) and other stuff

Attend SAEM every year if you can. Best collection of teaching, self-improvement and new research to be found.

Most importantly, find some clinical and basic science mentors. Get to know some basic scientists who do something related to EM (actually they all do). See what they do and what they want to know about our business. It always surprises me how much we can teach them and vice-versa.

The point of my post is if you are taking a pay cut to be an academic, be an academic. It frustrates me when somebody leaves 4-5 years after they started saying academics wasn't for them. Usually those same people never did anything academic! They did their shifts and taught a few lectures. Most turned down multiple opportunities that their chairs and divsion heads tried to interest them in. They get less out of those years than if they had gone private and faced the hordes alone. What a shame.

So I started out trying to help and it turned into a rant. Not the first time. Anyway you get the idea.

 

[Muscletoe]

I'm nearing the end of residency now, and was wondering if anyone would like to add to this. There's some great advice here, but if anyone has more, I'd love to hear it!

 

[RustedFox]

+1

 

[8654Marine]

Some great advice here.

Esp the part about being an attending in an academic institution.

I work in a community hospital. We have FM residents rotating thru our ED.

The biggest transition from a resident to an attending is being the arbiter of conflict resolution. A great attending has the ability to smooth any wrinkle: be it from patient, resident, family, or consultant or even another ED attending.

Being the calm amidst the cacophony is the ultimate.

To do this effectively, you have to know not just medicine, but also the players.

That means going outside the ED. Know the hospital. Be a part of committees, join various clubs.

How will you know you're on the right track? Once the families of consultants, nurses and administration, and even your ED colleagues ask for you by name, you'll get an idea.

Once you know the consultants, nurses, administration outside of the ED and can present yourself as a caring, knowledgeable professional, the next time you or your residents call at 0230am for an admit or belly consult, they know it's because you are trying to do the right thing. Folks will still grumble. Always will. But they'll know you'll do the same thing if it was their daughter or grandfather.

Don't mistake being liked = respect.

One thing, though: rely on yourself but don't get over-confident.

My biggest mistake: thinking residency prepared me for reality. I still learn new things and stopped assuming many things.

 

[leorl]

I think most new grads have a culture of working hard, but try to keep in the back of your mind the things you didn't like as a resident and don't do those things . For instance, there are some attendings in both academic and community settings that sit in the chair and play on the internet or do other academic work while having the residents or students see everybody, only stepping in when something major is going on or to shout and be accusatory.

I really resented that as a resident so I personally choose now to diffuse the workload of the residents when they're overwhelmed by taking my own patients, discharging their patients and making phone calls to PMDs or consulting services. Some argue that residents need to do all that because they're going to have to manage it some day, and while I agree, being overwhelmed isn't nice or pleasant for anybody. Apart from intern year, I don't think there is any educational benefit from calling PMDs etc.

Just a caveat that if you choose to diffuse workload that you don't take on too much in the beginning because then you get bogged down in trying to place orders / figure out the computers when you're new to a place.

On the flip side, and something I haven't gotten my hand around yet is developing your teaching style. Residents at some academic institutions like mine like to "discuss literature" and quote statistics, whereas I really don't think like that and I have a cursory at best knowledge of the most up-to-date stats. When I was a resident I hated the "do it because I'm your attending and I say so" reason for ordering things (like copious CT scans), so when I add to their orders I tell them I'm doing so and the reasons why. If they disagree with me, then I have an open discussion with them and take their reasons into consideration.

Some residents don't respond well to criticism and need the "that was a good attempt but..." approach, and some residents need the "that totally did not go well, you need to do X" approach and it's tricky figuring out who is who.

Another thing I find still disconcerting is if you're coming from a 3 year program but then go on to work at a 4-year academic institution. The whole senior being a middle man to "learn how to run the ED" to me seems very inefficient, and diffuses the educational experience for the junior. So although I fail sometimes, I try to have the junior present directly to me (some seniors don't like that) so I can discuss plans directly, or have both the senior and junior present when we discuss plans.

Last thing: make your authority known. You're very young looking and people at first, especially if you're female, may still mistake you for a resident rotator or a nurse. Dress professionally the first few times (then you can disintegrate into scrubs), and make it clear to the residents that you expect all the EKGs to come to you first, and that before doing a procedure it must be run by/supervised by you (some of my co-young attendings have walked into chest tubes and RSI being done without their supervision before and that is some scary @#$#! )

 

[leorl]

Oh and the other thing I was going to add is that obviously no one likes getting M&Ms, and you're going to try to avoid them but they're inevitable because someone somewhere inside and outside the hospital is going to complain about something.

Just realize that even very smart, wiser and more experienced attendings at your institution also get M&Ms and still sometimes go down the wrong treatment pathway despite their expertise. So don't be too worried if you have an M&M. You don't want to be the "one" who has a whole lot in their first year so just always have a reason (and document that reason on the chart) why you did x y z. One of mine was "stupid" and can be discounted, and my other one was because trauma got pissed off at me that I didn't admit to their service even though the patient obviously had major medical things going on.

Before you start clinically, it would be good to meet with the ED coders to explain to you the charting process and how you document MDM (medical decision making) and especially what things you can bill critical care for . I never thought about this stuff as a resident, but now that your salary will in some form or other be RVU based, I find it rather interesting now.

 

[Arcan57]

I really resented that as a resident so I personally choose now to diffuse the workload of the residents when they're overwhelmed by taking my own patients, discharging their patients and making phone calls to PMDs or consulting services. Some argue that residents need to do all that because they're going to have to manage it some day, and while I agree, being overwhelmed isn't nice or pleasant for anybody. Apart from intern year, I don't think there is any educational benefit from calling PMDs etc.

It's tough as a new attending in academics to adjust between moving the meat and supervision/teaching. If you're calling consults and PMDs for your residents routinel, you're hurting their education. It can be frustrating to know that it would take you 2 minutes to get a patient out the door, but that's not your role.

On the flip side, and something I haven't gotten my hand around yet is developing your teaching style. Residents at some academic institutions like mine like to "discuss literature" and quote statistics, whereas I really don't think like that and I have a cursory at best knowledge of the most up-to-date stats. When I was a resident I hated the "do it because I'm your attending and I say so" reason for ordering things (like copious CT scans), so when I add to their orders I tell them I'm doing so and the reasons why. If they disagree with me, then I have an open discussion with them and take their reasons into consideration....

... Another thing I find still disconcerting is if you're coming from a 3 year program but then go on to work at a 4-year academic institution. The whole senior being a middle man to "learn how to run the ED" to me seems very inefficient, and diffuses the educational experience for the junior. So although I fail sometimes, I try to have the junior present directly to me (some seniors don't like that) so I can discuss plans directly, or have both the senior and junior present when we discuss plans.

I have some issues with the above. If you're coming from a 3 yr (especially straight out of residency) to a 4yr program, you need to be sharper and more up to date than the senior residents. If evidence based medicine is the accepted standard and usual teaching modality, not being up to speed is going to make your changes to their plans sound like "because I said so".

Trying to cut the seniors out of the loop (whether for "efficiency" or because you can't deal with the challenge to your authority) shortchanges the seniors who are trying to learn pod management and develop a teaching style of their own. Your job is not to replace the senior but to act as a mentor and the voice of experience when the senior is stumped. If you see the senior is doing a crappy job of teaching the interns, call them on it and show them a better way. If you are in a hierarchical program, you need to respect the hierarchy under you as well as above.

 

[leorl]

I didn't mean to imply anywhere that I do not practice EBM, I think in this day and age everyone graduating from a residency has trained with current EBM and even have tried "newer" more recent methods, just that I don't have etched into my brain exact statistics and I believe many people don't, whether you're 3 or 4 year. I just bring that up as something that you may encounter when trying to develop your teaching style, which takes a different finesse than your practice style when you're not working with residents / midlevels.

If you're from a 3 year program and you break into a 4-year setting, you have already demonstrated somehow in the application process that you are "sharp." In my experience, I've actually been quite surprised that there is a reverse difference in the mentality between 3 yr and 4 yr trainees. I'm not going to turn this into a 3 vs. 4 yr debate, but I've been pleasantly surprised in how my training has held as well as disappointed in some lack of "basic" knowledge (minor, but still) in some of the residents in the 4 yr program. This is probably individual, as there are people from 3 and 4 year programs who probably should not be practicing.

Right, some people don't agree with me about the senior issue. I don't replace the senior at all and I don't want to, but one of the main depressing things for juniors is feeling like a scut slave and being kept out of the loop when management decisions are made about their patients between the senior and the attending. I try to minimize that by directly involving the junior and having the junior present to me or me + senior at the same time, and then go over management issues with both. It doesn't work all the time and especially if it's busy then the junior presents mainly to the senior. This doesn't in anyway shortchange the senior, they still run their patients and try to teach. I just try to engage the junior more than other people. The system is hierarchical, but I don't feel the need or have any desire to practice a strictly regimenedl hierarchy in my ED setting. Again, my own personal preference and I brought up this point to highlight a "new attending" thing to consider when switching settings.

I do disagree with the point made that an attending calling consults and PMDs for residents is detrimental to their education. I don't call ALL their services for them, but when it's busy and you add more and more busy work on an overloaded junior or even an overloaded senior, it is detrimental to absolutely everybody, from patient to nurse to resident and to attending and to overall workflow efficiency. In that setting, I can see absolutely no educational benefit to an attending calling a PMD or calling a consult service. They already get enough of it on a daily basis, and helping them in that way contributes to everyone's general well-being. Some people say that they make the residents do all of it so that they can learn to "feel the pressure" and become more efficient, but why should I want to add pressure when I already see them pressurized? Again, not everyone rolls like that but I do. Just another thing to consider when considering your teaching style at an academic institution.

 

[Arcan57]

I'd rather have the residents do everything on fewer patients than to take away some of their responsibilities. If you're calling the PMD as a courtesy (they're not admitting the patient to their service), then that's fine. If it's to get the patient admitted, then I feel strongly the resident needs to be having that conversation. It's can be painful but the repetitions are important, especially if the consult/PMD is difficult . Also, it reduces their sense of patient ownership if the patient is being dispositioned without them being involved. It's not a never thing, but there are other ways of helping out (seeing the chronic pain patients, walking a junior through a procedure so the senior can stay managing the pod, etc.)

 

[Birdstrike]

.

 

[TysonCook]

Best advice I got was don't ruffle any feathers your first year out. Play nice with EVERYONE, your first year out is like a first impression with the staff, and it can linger

It is NOT the time to redefine how your the new bad ***** on the block.

 

[deleted109597]

In general, I find the "seniors run the deparment" mantra a little odd. Sure, for that small percentage going into academics, it may help them. But in the community, if there's more than one doc, they're practicing independently. The other guys on shift don't check out to me. Nor do I help them with their dispos. You basically work in your own world.
Only academic attendings have other people present patients to them, except for the occasional midlevel asking an attending to help out.
I never "ran" my ED in residency. It wouldn't have been possible. We had 58 acute care beds. Hell, we never had less than 2 attendings, and sometimes we had up to 6. Even they weren't "running" the department.

As an aside, I agree with some of what leorl says. I too went to a residency where sometimes the only teaching I got during a shift was what the highest rated iphone app was, and the only help I got was them gently suggesting I go ahead and call the consultant, because they knew the medicine team was going to request it anyway. As a resident, I resented this greatly. As an attending, I see the wisdom in doing it for the senior residents, but I think helping out the overwhelmed intern/junior is better than letting them flounder. I do struggle sometimes in wanting to see a patient primarily to "help out" the residents, but this makes it harder for them to get to me if they've got questions on their patients.
I do think discharging patients for them after we've had the discussion about disposition does not take away from their education. They know how to discharge patients. If I think they need to practice sending away difficulty patients (seekers) I might let them handle that conversation, but if I can empty out a room while they're off doing something else, I will. I'm not going to go intubate or line up a patient without including them, but I still think calling a consultant occasionally is just helping make the place run smoothly.
But to routinely do it would make the resident get subpar training.

 

[Hamhock]

In general, I find the "seniors run the deparment" mantra a little odd. Sure, for that small percentage going into academics, it may help them. But in the community, if there's more than one doc, they're practicing independently. The other guys on shift don't check out to me. Nor do I help them with their dispos. You basically work in your own world. .

My sense is that this is true (but I have only worked in academics, admittedly).

However, the idea of a PGY4 running a department is nice in theory, but VERY difficult to make common practice (and maybe not that important, as Dr.McNinja points out).

Indeed, I haven't really seen it yet. I kinda remember the Denver PGY4s "running" the department, but that may just be my med student awe.

If you are running the whole department as a PGY4, I would ask if the department is too small or what "education" you are getting (vs. "protected" experience) as a PGY4.

I have yet to see a PGY3 ready to run a department....and, as Dr. McNinja points out, unless you are going to be at a teaching hospital, why would you require this experience?

I am starting to think that too many places are wasting their time on letting PGY4 believe they are "running the department".

(here's the controversial part)

That is not what a 4y program is about. (even though the 'education types' try to make the distinction).

HH

 

[Arcan57]

My sense is that this is true (but I have only worked in academics, admittedly).

However, the idea of a PGY4 running a department is nice in theory, but VERY difficult to make common practice (and maybe not that important, as Dr.McNinja points out).

Indeed, I haven't really seen it yet. I kinda remember the Denver PGY4s "running" the department, but that may just be my med student awe.

If you are running the whole department as a PGY4, I would ask if the department is too small or what "education" you are getting (vs. "protected" experience) as a PGY4.

I have yet to see a PGY3 ready to run a department....and, as Dr. McNinja points out, unless you are going to be at a teaching hospital, why would you require this experience?

I am starting to think that too many places are wasting their time on letting PGY4 believe they are "running the department".

(here's the controversial part)

That is not what a 4y program is about. (even though the 'education types' try to make the distinction).

HH

A couple of points:

1) Very few docs are going to have jobs where they aren't supervising anyone. For most of us it's not going to be residents, but I'll bet a lot of us are signing midlevels charts. It's not a 1:1 correlation, but it is helpful to be used to dealing with providers who have less experience and the common ways that leads to things going sideways.

2) I doubt there are many 4 year programs who's shop is small enough to be run by a single R4. However, having the R4 supervising interns in a pod setting allows the senior to get the experience of managing an ED, without the need for "pretending". In fact, I'm not entirely sure what the point of a 4 yr program without graduated responsibility is, other than to use the elective time to establish an academic career. The experience of running a large pod allows you to experience significantly more patient contact than you would just picking up your own patients. Now if you argue that 3 years completely prepares you to practice EM without any room for improvement, then the last point is irrelevant.

 

[EvoDevo]

To resurrect a bit....

Anyway, I'm going to be heading to a place that's single coverage for most of the day, and I wondered if any of y'all had recommendations on what I should have in my "jump kit." I was thinking of drip cards, a handy and small reference book (I believe in the stubby pencil method school of being prepared), a headlight....

Any other thoughts?

 

[leorl]

Tarascon and if you''re not totally comfortable with ortho when you graduate, a splinting card.

Another piece of advice - if you're going into community (or even academics), there's probably a couple logistic things you want to learn before you leave your residency, especially if you're going somewhere that might be more resource-poor or with nurses/staff who are not as used to critical care.
1) Know how to hook up a bipap machine
2) Know how to hook up a rapid transfuser
3) Know how to hook up a pleurvac

 

[RustedFox]

To resurrect a bit....

Anyway, I'm going to be heading to a place that's single coverage for most of the day, and I wondered if any of y'all had recommendations on what I should have in my "jump kit." I was thinking of drip cards, a handy and small reference book (I believe in the stubby pencil method school of being prepared), a headlight....

Any other thoughts?

EMRA has an airway/resusc. card that's pretty great. I'm sure someone on here has a link to it.

Two words: BROSELOW TAPE.

Actually - I'd be really interested if we could make a new thread with an "armory" of sorts that we all have or have found useful. I'd be happy to contribute. I have a "drip card" of sorts that I just printed out in small font, and slapped on the back of my EM Tarascon with clear tape.

Anyone wanna start this up ?

 

[deleted109597]

1) Very few docs are going to have jobs where they aren't supervising anyone. For most of us it's not going to be residents, but I'll bet a lot of us are signing midlevels charts. It's not a 1:1 correlation, but it is helpful to be used to dealing with providers who have less experience and the common ways that leads to things going sideways.

We all do, every day, even at places without residents. They're called nurses.

2) I doubt there are many 4 year programs who's shop is small enough to be run by a single R4. However, having the R4 supervising interns in a pod setting allows the senior to get the experience of managing an ED, without the need for "pretending". In fact, I'm not entirely sure what the point of a 4 yr program without graduated responsibility is, other than to use the elective time to establish an academic career. The experience of running a large pod allows you to experience significantly more patient contact than you would just picking up your own patients. Now if you argue that 3 years completely prepares you to practice EM without any room for improvement, then the last point is irrelevant.

Maybe running the department allows you more of a director role, but I still argue that when we are at work we work independently of each other. Even the midlevels don't present every chart to me (or 10%) for that matter.

 

[Arcan57]

Maybe running the department allows you more of a director role, but I still argue that when we are at work we work independently of each other. Even the midlevels don't present every chart to me (or 10%) for that matter.

That brings up an interesting point I hadn't thought much about. In single coverage shops and in academic centers, flow is usually directed by the EP. In double coverage situations, the diffusion of responsibility usually results in the charge nurse becoming the defacto flow coordinator. I'm an AD at my current shop, so when I'm working I will send people to the lobby, etc. (telling the midlevels, asking nicely of the attendings). If I wasn't an AD though, you're right that I'd be essentially independent of the other attending.

Also, my shop mandates 100% doc signs midlevel chart prior to pt. d/c.

 

[WilcoWorld]

Also, my shop mandates 100% doc signs midlevel chart prior to pt. d/c.

I think this is a good policy. We don't do that where I currently work. When I get a note to cosign 24 hours after the fact and I think, "Hmm, he ought to have done XYZ there" my only recourse is to call the patient back for a return visit, which I'm very unlikely to do.

 

[deleted109597]

Also, my shop mandates 100% doc signs midlevel chart prior to pt. d/c.

Not a bad idea, but we would drastically need to increase staffing to do so.

Of course, my problem is the opposite of WW. I'm frequently asking why they ordered so much crap.

 

[Arcan57]

Not a bad idea, but we would drastically need to increase staffing to do so.

Of course, my problem is the opposite of WW. I'm frequently asking why they ordered so much crap.

Like a CT and an ultrasound (but +/- a pelvic) on every female lower abdominal pain. Menstrual cramps should not be a 8 hr $8k work-up.

 

[docB]

That brings up an interesting point I hadn't thought much about. In single coverage shops and in academic centers, flow is usually directed by the EP. In double coverage situations, the diffusion of responsibility usually results in the charge nurse becoming the defacto flow coordinator. I'm an AD at my current shop, so when I'm working I will send people to the lobby, etc. (telling the midlevels, asking nicely of the attendings). If I wasn't an AD though, you're right that I'd be essentially independent of the other attending.

Also, my shop mandates 100% doc signs midlevel chart prior to pt. d/c.

Good point about how staffing changes the way flow works. I think the scenario you bring up where the charge or triage nurse basically directs the flow is felt most in where staffing is set up by pods or areas that have similar acuities. In my shops each shift starts in the high acuity area and then when the next shift starts (usually about 4 hours later) the first docs transitions to the fast track to finish up. That way the acuity drives the flow and there are fewer sign outs.

 

[EM_Rebuilder]

Good point about how staffing changes the way flow works. I think the scenario you bring up where the charge or triage nurse basically directs the flow is felt most in where staffing is set up by pods or areas that have similar acuities. In my shops each shift starts in the high acuity area and then when the next shift starts (usually about 4 hours later) the first docs transitions to the fast track to finish up. That way the acuity drives the flow and there are fewer sign outs.

I've heard of places starting a shift high acuity and finishing fast track... I think its makes sense to do it the other direction. Hear me out on this one...

I get run ragged by seeing many patients, not so much from seeing a few 'sick ones'. I would rather show up to a shift with feet to the ground and get my butt kicked for 4-6 hours, and then end it with sick patients that require more thinking/consults/maybe procedures, but less running around.

I agree with the point about how staffing changes the flow. When I occasionally moonlight in a small 4 bedroom place, I keenly look at whats in triage and often tell the nurses what I want back next and sometimes put them in a chair, etc. At my primary shop, I work in one pod of many. I loosely look at triage, but its hard to do that and direct anything to my or the other 3-6 pods going on... so essentially I loose interest and thus not that involved with flow.

 

[docB]

I've heard of places starting a shift high acuity and finishing fast track... I think its makes sense to do it the other direction. Hear me out on this one...

I get run ragged by seeing many patients, not so much from seeing a few 'sick ones'. I would rather show up to a shift with feet to the ground and get my butt kicked for 4-6 hours, and then end it with sick patients that require more thinking/consults/maybe procedures, but less running around.

I agree with the point about how staffing changes the flow. When I occasionally moonlight in a small 4 bedroom place, I keenly look at whats in triage and often tell the nurses what I want back next and sometimes put them in a chair, etc. At my primary shop, I work in one pod of many. I loosely look at triage, but its hard to do that and direct anything to my or the other 3-6 pods going on... so essentially I loose interest and thus not that involved with flow.

I should have mentioned that we also have PAs helping in fast track. The main problem with the reverse process you mention is that the workups are much longer in the acute area, e.g. an Xray for an ankle sprain vs. CT/LP and waiting on CSF results for a patient in the acute area. The beauty of the acute to fast track approach is that you don't sign out very many patients. After you transition to the fast track you can still finish up and dispo the longer work ups from the acute area. And when the PA hits a complex case you can recommend the work up and help them get going but leave the chart and the dispo to the next doc.

 

[WilcoWorld]

Not a bad idea, but we would drastically need to increase staffing to do so.

Of course, my problem is the opposite of WW. I'm frequently asking why they ordered so much crap.

I think you misunderstood me, and re-reading my post I can see why. Sure, sometimes I think the patient needed more work-up, but more often the "XYZ" means "not ordered a d dimer", "skipped the LFT's" or "done a pelvic exam but not a CT scan".