EM Last Lecture

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In the spirit of Randy Pausch's Last Lecture book, I thought it would be interesting to start an sdn "EM Last Lecture Series" for those of us who will be starting residency in the next 1-2 months. Would appreciate any advice/wisdom from the experienced attendings on here. Anecdotes, suggested resources, perspectives, or general life advice all are welcome. Thank you in advance for your "Last Lecture"
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Mr. Hat said:
I will pass on some wise words I received from my mentor. "There are exactly 2 reasons not to do a rectal exam: 1) They don't have a rectum. 2) You don't have a finger".

Bear these words in mind, young learner, and hold them close to your heart. After all, you don't want to be the guy who misses the occult lower GI bleed on the ankle sprain patient, do you?
Click to expand...
Yes i do .

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Mr. Hat said:
I will pass on some wise words I received from my mentor. "There are exactly 2 reasons not to do a rectal exam: 1) They don't have a rectum. 2) You don't have a finger".
Click to expand...

That's the worst advice ever. It sounds like advice from someone who didn't want to stick his fingers up people's butts, but was going to make sure he had a servant to do so for him. Classic surgery chief-resident BS.
 
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Birdstrike said:
That's the worst advice ever. It sounds like advice from someone who didn't want to stick his fingers up people's butts, but was going to make sure he had a servant to do so for him. Classic surgery chief-resident BS.
Click to expand...

I think that was tongue in cheek... which is far more sensitive and specific than DRE...
 
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1) The secret of patient care is caring for the patient.
2) Customer service matters, and the worst customer service I've ever seen has been in the ED. Pay attention when you go to a hotel or a restaurant at how people working for tips treat you. Then use those techniques. If you do, you'll never have to worry about your patient satisfaction scores because most nurses and doctors have no idea how to give good customer service. The bar is pretty low.
3) Know your limits. When you start getting uncomfortable, there's a reason. Load the boat.
4) Better to order an extra test or admit a patient that might not need it than to lie awake at night worrying about it.
5) While it's important not to facilitate addiction and criminal behavior, you're not a cop and neither are your nurses. Your role is not to catch every drug seeker in the world and make sure no one ever drives on narcotics. Being suspicious of a sketchy situation is okay, being cynical in every situation is not.
6) Learn how to be quick and efficient. Then do so when the situation calls for it. Cruise through the 90% of patients that require little thought so you have the time to spend on the other 10%.
7) Use the EMR to make you more efficient. Find the work arounds for the situations where it makes you less efficient. Free text boxes are your friend.
8) Empower your nurses. Back them up. Defend them. Buy them dinner. Be the doc that causes the nurses to sigh with relief when you walk in the door.
9) It's required that you say "no" sometimes. Not everyone needs narcotics. Not everyone needs a work note. Not everyone needs disability. Not everyone needs a CT.
10) Help your patients understand the concept of number needed to treat.
11) You probably won't come up with a definitive diagnosis for the majority of females between 15 and 45 with abdominal pain. Some are crazy, some are drug-seekers, some have diseases you don't have the tools to diagnose (endometriosis, ulcerative colitis), and some have diseases we don't yet understand. Get comfortable with uncertainty. Speaking of which, most chest pain is undiagnosable no matter how many specialists are called or tests are done. Get used to it. It's okay to discharge someone with diagnoses of "chest pain" and "abdominal pain."
12) Be the "dumb emergency doc." "I don't know what you have, but nobody goes home from my ED who can't eat, talk, walk, pee, and poop" (when they normally can.)
13) Be very careful giving up ownership. Ownership means more hassle in the short-term, but less in the long-term due to more money and most importantly, more control over your job-which matters far more for long-term job satisfaction.
14) Squirrels get sick too.
15) The most important thing when evaluating a job is the people you'll work with.
16) Just say yes to patient transfers. Even if the patient doesn't need to come to the ED, at least you're rescuing him from an incompetent "provider." Besides, transfers are good business since they're usually insured and if you're mean, that'll be the last one your ED gets from that clinic or urgent care.
17) Start your presentations to consultants with what you want them to do and why. "I want you to come in and scope this woman who has a steak in her esophagus." "I want you to admit Mrs. Sanchez because her sats are 82% and she has multi-lobar pneumonia." "I want you to look at Mr. Jones's forearm x-ray and let me know if this is surgical."
18) Figure out what your boss's/partners goals are and help him to achieve them.
19) Get your lovin' at home.
20) Emergency medicine is only a lifestyle specialty if you're working less than 120 hours a month. Beyond that point your lifestyle is no better than any other doctor's.
21) You will want to work fewer shifts and definitely fewer night shifts in the future. Plan your finances accordingly.
 
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(1) Don't be a di...Jerk
(2) You know nothing, and that's ok. Just stay humble and try to learn. Don't try showing up an attending w/ 15 years experience b/c you read an article a day ago...won't win you any favors
(3) Eat when you can, sleep when you can
(4) When off, find a (healthy) release. Exercise, fish, jog, join fight club, yoga, dress like a furry...whatever floats your boat. If you have a golden weekend, get out of town or try to plan some stuff to do.
(5) Don't forget about your family/friends. Make new friends with your fellow residents--they understand what you are going through more than anyone else
(6) Use face shields
 
The White Coat Investor said:
1) The secret of patient care is caring for the patient.
2) Customer service matters, and the worst customer service I've ever seen has been in the ED. Pay attention when you go to a hotel or a restaurant at how people working for tips treat you. Then use those techniques. If you do, you'll never have to worry about your patient satisfaction scores because most nurses and doctors have no idea how to give good customer service. The bar is pretty low.
3) Know your limits. When you start getting uncomfortable, there's a reason. Load the boat.
4) Better to order an extra test or admit a patient that might not need it than to lie awake at night worrying about it.
5) While it's important not to facilitate addiction and criminal behavior, you're not a cop and neither are your nurses. Your role is not to catch every drug seeker in the world and make sure no one ever drives on narcotics. Being suspicious of a sketchy situation is okay, being cynical in every situation is not.
6) Learn how to be quick and efficient. Then do so when the situation calls for it. Cruise through the 90% of patients that require little thought so you have the time to spend on the other 10%.
7) Use the EMR to make you more efficient. Find the work arounds for the situations where it makes you less efficient. Free text boxes are your friend.
8) Empower your nurses. Back them up. Defend them. Buy them dinner. Be the doc that causes the nurses to sigh with relief when you walk in the door.
9) It's required that you say "no" sometimes. Not everyone needs narcotics. Not everyone needs a work note. Not everyone needs disability. Not everyone needs a CT.
10) Help your patients understand the concept of number needed to treat.
11) You probably won't come up with a definitive diagnosis for the majority of females between 15 and 45 with abdominal pain. Some are crazy, some are drug-seekers, some have diseases you don't have the tools to diagnose (endometriosis, ulcerative colitis), and some have diseases we don't yet understand. Get comfortable with uncertainty. Speaking of which, most chest pain is undiagnosable no matter how many specialists are called or tests are done. Get used to it. It's okay to discharge someone with diagnoses of "chest pain" and "abdominal pain."
12) Be the "dumb emergency doc." "I don't know what you have, but nobody goes home from my ED who can't eat, talk, walk, pee, and poop" (when they normally can.)
13) Be very careful giving up ownership. Ownership means more hassle in the short-term, but less in the long-term due to more money and most importantly, more control over your job-which matters far more for long-term job satisfaction.
14) Squirrels get sick too.
15) The most important thing when evaluating a job is the people you'll work with.
16) Just say yes to patient transfers. Even if the patient doesn't need to come to the ED, at least you're rescuing him from an incompetent "provider." Besides, transfers are good business since they're usually insured and if you're mean, that'll be the last one your ED gets from that clinic or urgent care.
17) Start your presentations to consultants with what you want them to do and why. "I want you to come in and scope this woman who has a steak in her esophagus." "I want you to admit Mrs. Sanchez because her sats are 82% and she has multi-lobar pneumonia." "I want you to look at Mr. Jones's forearm x-ray and let me know if this is surgical."
18) Figure out what your boss's/partners goals are and help him to achieve them.
19) Get your lovin' at home.
20) Emergency medicine is only a lifestyle specialty if you're working less than 120 hours a month. Beyond that point your lifestyle is no better than any other doctor's.
21) You will want to work fewer shifts and definitely fewer night shifts in the future. Plan your finances accordingly.
Click to expand...
That's a pretty good list.
 
Protect your sleep. Use whatever tricks you have to (blackout curtains, white noise machine, etc). But absolutely protect your sleep. 20 mg of melatonin during the nighttime hours helps a lot.
 
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Three cardinal rules for residency:

1) Don't be Late.
2) Don't be Lazy.
3) Don't Lie.
 
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Daiphon said:
Someone has to look up the immunization status during a code... could be tetanus. d;-)
Click to expand...
The only time I didn't hate going to codes as an IM intern was when my co-intern was an EM resident or my senior was an R3 going into CCM. I always jumped into doing compressions so I could look useful and not have to be in charge.

[/threadjack]
 
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The White Coat Investor said:
I just realized the OP was talking about people starting residency, not leaving. I've got a whole different list for starting residents, but I guess some of the stuff on that list might be useful to a new resident too.
Click to expand...

Do you mean you have a list for folks about to leave residency/become an attending? As somebody a year away from doing so I'd love to see it.
 
namethatsmell said:
Do you mean you have a list for folks about to leave residency/become an attending? As somebody a year away from doing so I'd love to see it.
Click to expand...

We did this awhile back. Some folks called it the "jump kit" - i.e. - the gear (and ideas) that you want to have when you "make the jump".
 
RustedFox said:
We did this awhile back. Some folks called it the "jump kit" - i.e. - the gear (and ideas) that you want to have when you "make the jump".
Click to expand...

Cool, I'll look it up.

My tip for incoming interns: If you're thinking about getting an xray...just get the xray (major exception being LBP without red flags).
 
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Daiphon said:
Someone has to look up the immunization status during a code... could be tetanus. d;-)
Click to expand...

I actually had a patient who sustained significant arterial and venous injury from knife wounds... I work in the boonies and immediately applied pressure dressings and called an ambulance to take the patient to the trauma center.... Nurse thought I was a bad doc for "not doing anything" and asked why I didn't give a tetanus booster.
 
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Don't date in the hospital. Staff can find another job. The program can find another resident. You on the other hand...

Erase and delete all your social media...

Try and find a way to put some money aside to payyour student loans.

Don't buy a house...

Get the best iPhone you can, EMRAP, EMCRIT, and CEME's board review audios and make your commute productive...

Somehow find the time to get to the gym.

Don't eat junk food.

Those last two are good advice in general but surprisingly hard to do on a resident schedule.
 
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Old_Mil said:
Don't date in the hospital. Staff can find another job. The program can find another resident. You on the other hand...

Erase and delete all your social media...

Try and find a way to put some money aside to payyour student loans.

Don't buy a house...

Get the best iPhone you can, EMRAP, EMCRIT, and CEME's board review audios and make your commute productive...

Somehow find the time to get to the gym.

Don't eat junk food.

Those last two are good advice in general but surprisingly hard to do on a resident schedule.
Click to expand...
I gotta question some of this advice. Why would you recommend deleting your social media? That seems unnecessarily paranoid, it's quite easy to stay hidden, at least on Facebook.

Is it really a necessity to try to pay off some of your student loans during residency? Unless bringing in some significant moonlighting money, you're probably only going to be able to put $5-10k/yr towards your debt as a resident (not even enough to pay off the interest in most cases). Why not just hang onto that money, build a nice little nest egg, and enjoy your time in residency without living paycheck to paycheck? Just live like a resident for an extra half a year as an attending, and you'll put the same dent into your debt that you would have during all 3 years of your residency.

The "don't buy a house" advice is incredibly regional and individual specific. There are some locations where buying a house makes more financial sense than renting for the 3-4 years of residency. Also, some individuals plan to stay in the area where they trained.
 
Zebra Hunter said:
I gotta question some of this advice. Why would you recommend deleting your social media? That seems unnecessarily paranoid, it's quite easy to stay hidden, at least on Facebook.
Click to expand...

If you want to make your profile private and never post anything work related to it, you can. The idea is to have a complete firewall between your work and personal life.

Is it really a necessity to try to pay off some of your student loans during residency? Unless bringing in some significant moonlighting money, you're probably only going to be able to put $5-10k/yr towards your debt as a resident (not even enough to pay off the interest in most cases). Why not just hang onto that money, build a nice little nest egg, and enjoy your time in residency without living paycheck to paycheck? Just live like a resident for an extra half a year as an attending, and you'll put the same dent into your debt that you would have during all 3 years of your residency.
Click to expand...

The reason is that you'll be surprised at how quickly a 250,000 loan balance can grow at 6.8% plus per year. You aren't going to match let anyone exceed that on savings invested in anything that will keep the principal relatively safe. A few dollars thrown at the thing in residency will pay dividends later.

There are some locations where buying a house makes more financial sense than renting for the 3-4 years of residency. Also, some individuals plan to stay in the area where they trained.
Click to expand...

While it is true that people stay nearby where they train for the most part this doesn't necessarily mean that the location they want to be in residency will be a good choice for their attending job. Children and school districts come into play. A surprising number of residents change fields, change programs, or get fired. Even if you aren't stretching your budget as an attending there is room to get a better house than you would have as a resident and still spend responsibly. So I wouldn't change that advice.
 
Angry Birds said:
I actually had a patient who sustained significant arterial and venous injury from knife wounds... I work in the boonies and immediately applied pressure dressings and called an ambulance to take the patient to the trauma center.... Nurse thought I was a bad doc for "not doing anything" and asked why I didn't give a tetanus booster.
Click to expand...
Not surprising. Not. At. All.

cf the thread on APN training, understanding, and scope of practice. :::shudder:::
 
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The reason is that you'll be surprised at how quickly a 250,000 loan balance can grow at 6.8% plus per year. You aren't going to match let anyone exceed that on savings invested in anything that will keep the principal relatively safe. A few dollars thrown at the thing in residency will pay dividends later.
Click to expand...
I wouldn't be surprised because I know exactly how quickly it would grow at that rate. And I realize that it is almost impossible to get a ROI greater than or equal to the interest on my loans, my point was, why bother trying to pay it down in residency, especially when your residency is only 3 years? Its only going to be a drop in the bucket, and rather than dedicate a significant portion of my salary to it, I'd rather be able to travel somewhere nice for my weeks off and build up some savings just in case something catastrophic happened. Like I said, assuming you are only able to put $5-10k/yr towards your debt during residency, accounting for interest, you'd be able to make up the difference in less than half a year on an attending salary.

I guess what I'm saying is I personally disagree with the philosophy because I value security and peace of mind more than getting the most out of my money.
 
Agree with Zebra Hunter; I did not pay a dime towards my loans in residency. Life is too short, youth is shorter. Enjoy it.
 
RustedFox said:
Agree with Zebra Hunter; I did not pay a dime towards my loans in residency. Life is too short, youth is shorter. Enjoy it.
Click to expand...
Same here. The "live like you're a resident until your loans are paid off" mindset, though noble, can be a little extreme for some. You've got to reward yourself a little. Deferred gratification is good to a point, but you've got to live in the now sometimes also, otherwise you may never get to reap any of the benefits of your hard work. You're not going to live forever. I've seen docs younger than me get sick and die. Live a little.
 
I agree generally with this sentiment and chose instead to max a Roth IRA since that's space you'll never have again to use up at this tax bracket. All my moonlighting money except for a nice flatscreen went to loans.


Sent from my iPhone using Tapatalk
 
future_dr_house said:
I agree generally with this sentiment and chose instead to max a Roth IRA since that's space you'll never have again to use up at this tax bracket. All my moonlighting money except for a nice flatscreen went to loans.
Click to expand...

That's exactly the balance you're looking for. Spend a little, save a little, be better off next year than you were this year. Grow into your income as slowly as you can without feeling impoverished.
 
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