How to become a crappy ER doctor

[Birdstrike]

Since this is a thread on how not to become a crappy ER doctor, do we need a twin thread on "How to become a crappy ER doc"?

It could be pretty entertaining.

Do I have a second?

Second!

Go

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[The White Coat Investor]

Here are a few ways to become a crappy ER doc.

1) Do exactly what you are paid best to do.
2) Do exactly what hospital admin tells you to do.
3) Forget that doing the right thing is the most important thing.
4) Work part time your first two years out of residency.
5) Assume that doing the amount of CME required by your state or ACEP is adequate.
6) Forget to use your state controlled substance database when evaluating patients with pain.
7) Work so many shifts or at such a high pace that you run out of compassion for your patients.
8) Screw up your personal finances so badly that you need the job more than the job needs you.
9) Don't call surgeons when their patient comes in with a post-op issue.
10) Forget that tests and admissions have risks.
11) Quit picking up patients two hours before the end of your shift, especially in a single coverage shop.

I'm sure someone else can add to the list.

 

[Arcan57]

12) Ignore the little voice in the back of your head.
13) Be unquestioning when what the consultant on the phone says makes no sense when applied to the patient in front of you.
14) Ignore the nurses when they're concerned about a patient.
15) Routinely deny your body the sleep and nutrition necessary to fully functional during a shift.
16) Act like your job only exists during the hours of your shift.
17) Stop trying to connect with patients.
18) Never read a progress note or discharge summary on patients you've admitted, especially when starting out.
19) Reflexively tell yourself "that's not something I need to know about" when you run into novel concepts.
20) Never factor in the patient's ability to follow through with your plan of care when crafting said plan.
21) Let the nurse take care of educating and discharging the patient.
22) Assume that you have no responsibility for the conditions in your work environment.

 

[Serous Demilune]

12) Ignore the little voice in the back of your head.
13) Be unquestioning when what the consultant on the phone says makes no sense when applied to the patient in front of you.
14) Ignore the nurses when they're concerned about a patient.
15) Routinely deny your body the sleep and nutrition necessary to fully functional during a shift.
16) Act like your job only exists during the hours of your shift.
17) Stop trying to connect with patients.
18) Never read a progress note or discharge summary on patients you've admitted, especially when starting out.
19) Reflexively tell yourself "that's not something I need to know about" when you run into novel concepts.
20) Never factor in the patient's ability to follow through with your plan of care when crafting said plan.
21) Let the nurse take care of educating and discharging the patient.
22) Assume that you have no responsibility for the conditions in your work environment.

Can you elaborate on #16?

 

[Arcan57]

Can you elaborate on #16?

EM is shift work but it is still medicine. Medicine is a dynamic field and rewards those who take the time to keep abreast of current developments as well as spend time reflecting on opportunities for personal improvement. That's kind of a wanker way of saying that if EM is just what you do to pay the bills and you don't allow yourself to make time outside of your shifts to study and try to do better then your skills are going to erode and your knowledge base is going to become obsolete.

 

[Meh.meh]

12) Ignore the little voice in the back of your head.
13) Be unquestioning when what the consultant on the phone says makes no sense when applied to the patient in front of you.
14) Ignore the nurses when they're concerned about a patient.
15) Routinely deny your body the sleep and nutrition necessary to fully functional during a shift.
16) Act like your job only exists during the hours of your shift.
17) Stop trying to connect with patients.
18) Never read a progress note or discharge summary on patients you've admitted, especially when starting out.
19) Reflexively tell yourself "that's not something I need to know about" when you run into novel concepts.
20) Never factor in the patient's ability to follow through with your plan of care when crafting said plan.
21) Let the nurse take care of educating and discharging the patient.
22) Assume that you have no responsibility for the conditions in your work environment.

Is 18 a hipaa violation?

 

[Tiger26]

Is 18 a hipaa violation?

No--they're your patient

 

[TooMuchResearch]

No--they're your patient

I've had some interesting surprises following up on my patients so far in residency.

Residents, we definitely need to do this.

 

[WilcoWorld]

23) Convince yourself that the way medicine was practiced in your residency's ED was The Right Way and refuse to adjust your practice when starting new jobs.
24) Assume that the one and only measure of good care is whether or not you get sued, and conclude that, so long as you haven't been sued you're providing good care.

 

[Birdstrike]

25) Place 5/5 Press-Ganey scores over what's best for patients.

 

[MSmentor018]

I've had some interesting surprises following up on my patients so far in residency.

Residents, we definitely need to do this.

I am 2 yrs out and still do this regularly. it's a great learning tool esp to see what the subspecialist thinks, did they find something on exam that you didn't, were you aggressive enough in treatment, too much? how effective was the nerve block? if you've seen it once, somewhere down the line you're going to see it again.

26) be angry and yell at the staff

 

[WilcoWorld]

I am 2 yrs out and still do this regularly. it's a great learning tool esp to see what the subspecialist thinks, did they find something on exam that you didn't, were you aggressive enough in treatment, too much? how effective was the nerve block? if you've seen it once, somewhere down the line you're going to see it again.

I've learned a lot from doing this. Also, it can boost your confidence. Like when you admit someone to the MICU after resuscitating them in the ED, but having no idea what was wrong with them...you follow up on them 5 days later to learn that the MICU continued your ED care, they got better and were discharged with a diagnosis of "Fever, hypotension, altered mental status - resolved" aka "he was really sick, and we're not sure what caused it, but he's better now."

 

[WilcoWorld]

27) Don't read discharge summaries.

28) Don't review med lists on nursing home patients.

29) Don't look at Radiology studies yourself, or even read the full report - just read the "impression".

 

[eefen]

Here are a few ways to become a crappy ER doc.

1) Do exactly what you are paid best to do.
2) Do exactly what hospital admin tells you to do.
3) Forget that doing the right thing is the most important thing.
4) Work part time your first two years out of residency.
5) Assume that doing the amount of CME required by your state or ACEP is adequate.
6) Forget to use your state controlled substance database when evaluating patients with pain.
7) Work so many shifts or at such a high pace that you run out of compassion for your patients.
8) Screw up your personal finances so badly that you need the job more than the job needs you.
9) Don't call surgeons when their patient comes in with a post-op issue.
10) Forget that tests and admissions have risks.
11) Quit picking up patients two hours before the end of your shift, especially in a single coverage shop.

I'm sure someone else can add to the list.

How do you reconcile #4 with doing a fellowship straight out of residency? I've heard before that the first couple of years out on your own carry a huge learning curve, and I've wondered how that works if you are only working a shift or maaaybe two a week in the ED while doing sports medicine, pain, etc.

 

[deleted547339]

How do you reconcile #4 with doing a fellowship straight out of residency? I've heard before that the first couple of years out on your own carry a huge learning curve, and I've wondered how that works if you are only working a shift or maaaybe two a week in the ED while doing sports medicine, pain, etc.

Also curious about this...

 

[The White Coat Investor]

How do you reconcile #4 with doing a fellowship straight out of residency? I've heard before that the first couple of years out on your own carry a huge learning curve, and I've wondered how that works if you are only working a shift or maaaybe two a week in the ED while doing sports medicine, pain, etc.

If you're in fellowship you're not "out" yet. But the rule still applies. The best way to solidify your EM skills after residency is to go practice EM, not work one shift a week while farting around in a sports medicine clinic. However, if you want to develop some other skills (like bow staff skills or sports medicine skills) then sure, do a fellowship.

 

[HunterGatherer]

I am 2 yrs out and still do this regularly. it's a great learning tool esp to see what the subspecialist thinks, did they find something on exam that you didn't, were you aggressive enough in treatment, too much? how effective was the nerve block? if you've seen it once, somewhere down the line you're going to see it again.

I'm a fan of this.

30) Don't thank anyone as you walk out at the shift end especially the clerk, ER Techs, housekeeping, nurses, or anyone else because you singlehandedly saved the day by clinching the diagnosis.

 

[eefen]

If you're in fellowship you're not "out" yet. But the rule still applies. The best way to solidify your EM skills after residency is to go practice EM, not work one shift a week while farting around in a sports medicine clinic. However, if you want to develop some other skills (like bow staff skills or sports medicine skills) then sure, do a fellowship.

So for someone interested in doing a fellowship, would you then recommend practicing for 1-2 years out of residency and then going back, or just going straight through? I know it's not really "ideal" either way, but it seems like the general consensus is to just get the fellowship done while you are still in that mode.

 

[Daiphon]

So for someone interested in doing a fellowship, would you then recommend practicing for 1-2 years out of residency and then going back, or just going straight through? I know it's not really "ideal" either way, but it seems like the general consensus is to just get the fellowship done while you are still in that mode.

Either way you'll get pro/con.

I addressed this by working single-coverage overnights 2x weekly during fellowship.

Skills got better, my style got honed, and the $$$ sure was nice...

-d

 

[eefen]

Either way you'll get pro/con.

I addressed this by working single-coverage overnights 2x weekly during fellowship.

Skills got better, my style got honed, and the $$$ sure was nice...

-d

Was this at a lower-volume place where you could at least catch a little bit of sleep, or were you just powering through the week with two nights of missed shut eye?

 

[Birdstrike]

So for someone interested in doing a fellowship, would you then recommend practicing for 1-2 years out of residency and then going back, or just going straight through? I know it's not really "ideal" either way, but it seems like the general consensus is to just get the fellowship done while you are still in that mode.

I say do it as early as you can. You can do either, but the longer you're out, the harder to go back. If for nothing else, simply due to lifestyle creep. The longer you're used to the attending salary, the harder to go back to a resident one even for a year or two. It can be done, though. I did it, but it was hard. You can moonlight during to keep your skills up if you are worried you'll get rusty, time permitting depending on the fellowship.

 

[Daiphon]

Was this at a lower-volume place where you could at least catch a little bit of sleep, or were you just powering through the week with two nights of missed shut eye?

Technically "low volume" of ~20-25k/year. But, as another thread on here somewhere can attest, "low volume" is not equivalent to "low acuity" - especially when you're the only doc in the whole damn county after 5pm and you get every STEMI/CVA/ICH/OD/trauma/surgical abdomen/yada yada yada, and no real services on site other than the ED. Some nights, got a nap. Others, not so much.

Highly recommend it. d=)

-d

 

[eefen]

Technically "low volume" of ~20-25k/year. But, as another thread on here somewhere can attest, "low volume" is not equivalent to "low acuity" - especially when you're the only doc in the whole damn county after 5pm and you get every STEMI/CVA/ICH/OD/trauma/surgical abdomen/yada yada yada, and no real services on site other than the ED. Some nights, got a nap. Others, not so much.

Highly recommend it. d=)

-d

Sounds like a hell of a way to start things off!

 

[SoCuteMD]

How do you reconcile #4 with doing a fellowship straight out of residency? I've heard before that the first couple of years out on your own carry a huge learning curve, and I've wondered how that works if you are only working a shift or maaaybe two a week in the ED while doing sports medicine, pain, etc.

I did a simulation fellowship and worked 16 clinical hours a week. That provided a good balance and allowed me to work as an attending. I moonlighted a fair amount as well (an additional 25 hours a month or so). I did the math and I ended up working about 120 hours less for the year than a full time academic attending by the time all was said and done.

 

[RustedFox]

31.) Sign-out pelvic exams. What; nobody got that'n yet ?!

32.) Try to fit everyone into a 'diagnostic box' instead of actually listening to the patient. I swear; if you just shut up and listen, really listen to what the patient has to say.... 90% of your mental work is already done for you.

33.) Don't read the nursing notes. SMH.

 

[Birdstrike]

This actually turned out to be a very useful thread. I thought it would degenerate into an unserious laugh-fest, but it's actually turned into a pretty good list of do's and don'ts. A lot of it is stuff you have to learn in the real world, the hard way.

 

[Doctor Bob]

I addressed this by working single-coverage overnights 2x weekly during fellowship.

I did a simulation fellowship and worked 16 clinical hours a week. That provided a good balance and allowed me to work as an attending. I moonlighted a fair amount as well (an additional 25 hours a month or so).

I'm doing a critical care fellowship and working 80hrs a week. Moonlighting... just not very feasible. I may get to the point where I do a shift every 2 or 3 weeks, but right now the time with my family is more important.

But... I also worked for 2 years after getting out of residency. So there's that.

 

[Arcan57]

34) Ignore c-spine clearance in the elderly with head trauma. Old people never break their neck from ground level falls or even stumbling face first against a wall.
35) Assume a positive UA in an old person with belly pain means you've found the source of the problem.

 

[WilcoWorld]

I'm doing a critical care fellowship and working 80hrs a week. Moonlighting... just not very feasible. I may get to the point where I do a shift every 2 or 3 weeks, but right now the time with my family is more important.

But... I also worked for 2 years after getting out of residency. So there's that.

I also think that CC is a fellowship where your essential skills are unlikely to atrophy.

 

[UTFamMedDoc]

36) Piss off the nurses

 

[WilcoWorld]

37) Call consultants and/or receiving hospitals before actually examining a patient.