How to prepare for community job out of residency

[TrailRun]

Hi all,

Will be working at a single coverage (+/- PA) shop with no OB straight out of residency. Coming from an academic-heavy program with not much community time. I know I'm lucky to have a job at all! I know some things will certainly be different (i.e. an arrest won't have extra residents to throw in random central lines, no luxury of time to place a pacer while someone else covers the pod, etc). Any tips, or things you wish you knew prior to starting?

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[Birdstrike]

Hi all,

Will be working at a single coverage (+/- PA) shop with no OB straight out of residency. Coming from an academic-heavy program with not much community time. I know I'm lucky to have a job at all! I know some things will certainly be different (i.e. an arrest won't have extra residents to throw in random central lines, no luxury of time to place a pacer while someone else covers the pod, etc). Any tips, or things you wish you knew prior to starting?

This was me, exactly 18 years ago. My advice would be to:

1) Have an open mind. Realize there will be new ways to do things that you'll have to learn that don't seem "academic-perfect" but will suffice.

2) Realize you will continually and rapidly learn for the first 6 months to a year. Remind yourself of this on days you feel like your confidence is tested.

3) Try to have fun and be proud of yourself that you've finally made it.

4) Realize you're greatly appreciated for what you do, even if you're not reminded of that, as much or as often you should be, from the people who should be telling you so.

 

[Groove]

You'll be fine and likely have been more than prepared to be able to handle yourself. A little first job jitters is normal, especially for those that haven't moonlighted too much in residency. You got this!

Just remember, you can always call up the local tertiary care center for assistance with a case. It doesn't always have to result in a transfer.

 

[gutonc]

I just want to say that the advice given above by @Groove and @Birdstrike is both excellent and universal. I kind of wish I could move this to Gen Res since it's something pretty much everyone in residency/fellowship/practice, regardless of specialty, could learn from, but won't.

My take (as a non-EM person):
1. Don't be a dick. To anyone. Don't roll over and take anybody's s***, but don't be the person dishing it out.
2. Recognize your limitations (personally and systemically) and don't be afraid to ask for help (local consultant, that RN that's been in the department for 20 years, "phone a friend" at the nearest trauma/tertiary center or a former mentor colleague).
3. Learn something every day and from every interaction you have with a patient or consultant.

These too are meant to be universal, but I think will serve you well.

 

[RustedFox]

1. Placement comes first.

 

[bravotwozero]

Make sure your metrics are not an outlier, at least not in a negative direction. That will get you into trouble in the community.

 

[RuralEDDoc]

Just remember, you can always call up the local tertiary care center for assistance with a case. It doesn't always have to result in a transfer.

Really? I don’t think this is accurate. I’m typically happy to help another doc but if I got a call from another hospital asking to “run a case by me”, I would outright refuse.

 

[GeneralVeers]

Really? I don’t think this is accurate. I’m typically happy to help another doc but if I got a call from another hospital asking to “run a case by me”, I would outright refuse.

Correct. Same here. I don't want to risk having my name put on a chart as giving advice for a patient I haven't seen.

 

[RuralEDDoc]

Correct. Same here. I don't want to risk having my name put on a chart as giving advice for a patient I haven't seen.

Yes, that’s a big part. Beyond that, it’s the responsibility of a hospital to manage its call panel and EM group to manage their own clinical quandaries. Call your medical director with process questions, since that’s the person being paid to manage the EM group. Don’t call a tertiary care ER where the doc on service is not paid to help answer questions; that is not the point of EMTALA.

 

[emergentmd]

1. Buy donuts for the nurse manager daily and kiss up to the nurses
2. Give all pts antibiotics
3. Click pt quickly once they hit the board, but not so quick where you assign yourself to 2 pts in similar times
4. Don't mess up a metric.
5. Don't be an outlier of any metric. yes that means low or high. Fly right in the middle on everything
6. Take all admissions and never refuse

 

[Kryptocoin]

Really? I don’t think this is accurate. I’m typically happy to help another doc but if I got a call from another hospital asking to “run a case by me”, I would outright refuse.

I call tertiary pediatric hospitals once a year or so and run a case by them. They love stuff like this and are very helpful. I definitely would help another ER doctor from an outside hospital. It's extremely low risk but fosters a sense of camaraderie. In the last 50yrs , how many successful legal suits have come from this? Can't think of any........


What I won't do though is be the "consult" for an NP/PA at an outlying facility. I don't trust their clinical judgement or skills. I have no clue if what they're telling me over the phone is accurate. I automatically accept the patient and assess them myself or have them call their medical director.

 

[gamerEMdoc]

I think its important to realize the standard of care is different. If you are single coverage and have 15 active patients, and plenty more in the WR you can't be doing unnecessary procedures that can be done by your consultants. Im not saying punt all procedures, definitely not do that. But if you are in a job with one nurse and one doc, it may not make sense to float a transvenous pacer if you can transcutaneously pace someone and get them to an interventional cardiologist. The key is knowing your resources that you have at your hospital, knowing what your staff can handle, and realizing you have to do your best for all the patients under your care, to the best of your ability. Standard of care legally is regionally defined. The standard of care for a multisystem trauma patient is not the same in a 10 bed, 1 nurse ED as it is in a 100 bed level 1 trauma center. You just have to do your best, and realize when its best to punt so you can move on based on the number of your resources.

That being said, getting out and working on your own outside of big academia is a great learning experience. And often times very rewarding if you work at a hospital with good staff/consultants.

 

[bravotwozero]

Whenever possible, never put all of your employment eggs in one basket. Ideally, try to have at least one part time time/prn job with a different group in addition to your full time position. You never know if/when things will go south, and you should try to leave yourself an out, so you're not stuck a few months without a paycheck while applying or getting credentialed for a new job. Especially true if you're a 1099, where you can be fired without cause for so much as looking at someone funny. You'll be amazed at some of the reasons EPs have lost their jobs. I myself have learned this lesson the hard way.

 

[RustedFox]

Whenever possible, never put all of your employment eggs in one basket. Ideally, try to have at least one part time time/prn job with a different group in addition to your full time position. You never know if/when things will go south, and you should try to leave yourself an out, so you're not stuck a few months without a paycheck while applying or getting credentialed for a new job. Especially true if you're a 1099, where you can be fired without cause for so much as looking at someone funny. You'll be amazed at some of the reasons EPs have lost their jobs.

The bolded is a HUGE problem in EM.

We have zero "security" in as much as our job situation can change like crazy.

Every job I have ever had in EM has changed radically while I was there, in terms of "who has the contract", or "here's the new coverage map" (which no doc actually working there had any input into).

Every. Single. One.

There is no "oh, my job is good, I'm keeping it for a decade or so".

ANY job can go south at any time, and in my experience, it eventually will.

 

[Mount Asclepius]

Whenever possible, never put all of your employment eggs in one basket. Ideally, try to have at least one part time time/prn job with a different group in addition to your full time position. You never know if/when things will go south, and you should try to leave yourself an out, so you're not stuck a few months without a paycheck while applying or getting credentialed for a new job. Especially true if you're a 1099, where you can be fired without cause for so much as looking at someone funny. You'll be amazed at some of the reasons EPs have lost their jobs.

I used to agree with the sentiment of this post. However, I don’t agree with this anymore. You should at the minimum have a 3-6 month emergency fund, and have the wherewithal to quickly relearn how to live like a student if financially stressed. Over time you should definitely get to the point where you aren’t living paycheck to paycheck on the gradual path to FIRE. After a while, one full time job is fine as you should be comfortably able to go a few months without a paycheck.

 

[RustedFox]

The bolded is a HUGE problem in EM.

We have zero "security" in as much as our job situation can change like crazy.

Every job I have ever had in EM has changed radically while I was there, in terms of "who has the contract", or "here's the new coverage map" (which no doc actually working there had any input into).

Every. Single. One.

There is no "oh, my job is good, I'm keeping it for a decade or so".

ANY job can go south at any time, and in my experience, it eventually will.

Yeah, I'm going to quote my own post.

At my very first job, we had a full roster of 6 full-time docs and a few PRN docs. We had a FULL roster.
Then, everyone EXCEPT ME either quit, retired, moved, or found other work, because "metrics" became the most important thing.
All of a sudden, I went from fifteen 8-hour shifts a month (reasonable) to 16-17 twelve-hour shifts a month, because "we need the coverage, and you're the last man standing, so buckle up".


At another job, everything was cool until Administration got divorced from the University system that the hospital was a part of.
New everything. No more benefits that we counted on prior. Almost everyone quit. I moved on, because I had found other work.


At another job, everything was cool until Administration started being a diva about the CMG contracts. We had 3 CMGs in a little over a year come and go. Eventually, I said - "What good is a contract if one party can change it anytime they want to?"



This is the state of EM today.

 

[bravotwozero]

I used to agree with the sentiment of this post. However, I don’t agree with this anymore. You should at the minimum have a 3-6 month emergency fund, and have the wherewithal to quickly relearn how to live like a student if financially stressed. Over time you should definitely get to the point where you aren’t living paycheck to paycheck on the gradual path to FIRE. After a while, one full time job is fine as you should be comfortably able to go a few months without a paycheck.

I completely agree that you should not be living paycheck to paycheck. If you're doing this as an attending a few years out of residency, there's a problem. However, having multiple jobs and having enough savings are not mutually exclusive! why not do both if you can? The more layers of financial security you have, the better.

 

[Groove]

Really? I don’t think this is accurate. I’m typically happy to help another doc but if I got a call from another hospital asking to “run a case by me”, I would outright refuse.

Specialists. It's very easy and I did it every now and again when I as moonlighting as a resident in an ER out in the middle of nowhere. These are people that are on call at the tertiary care center and, in general, were always happy to help. In fact, they were even more happy that it was something that wasn't going to have to be transferred.

I've never been called for help with a case in the ED, but if I did I would have no problem giving advice over the phone. You guys are harsh. It's a recorded line, all you have to do is say that you're limited in your ability to advise given that you can't examine the pt but given his or her description of the case, I would recommend x, y, z. It's not your patient, it's their patient. You're not managing them, he or she is. Just imagine how you'd feel if the pt had a bad outcome or died and it was because you failed to give advice for a struggling new doc who tried to call you for assistance and you wouldn't give it. If he puts your name down, so what? No jury in the world would find you at fault in a case like that.

Anyway, consulting the tertiary care center is easy and I never had a problem with it way back then. Cards, GI, nephrology, peds....all were very helpful. It's a resource that most new docs working in a small, sleepy, rural ER forget that they have available to them.

 

[bravotwozero]

Yeah, I'm going to quote my own post.

At my very first job, we had a full roster of 6 full-time docs and a few PRN docs. We had a FULL roster.
Then, everyone EXCEPT ME either quit, retired, moved, or found other work, because "metrics" became the most important thing.
All of a sudden, I went from fifteen 8-hour shifts a month (reasonable) to 16-17 twelve-hour shifts a month, because "we need the coverage, and you're the last man standing, so buckle up".


At another job, everything was cool until Administration got divorced from the University system that the hospital was a part of.
New everything. No more benefits that we counted on prior. Almost everyone quit. I moved on, because I had found other work.


At another job, everything was cool until Administration started being a diva about the CMG contracts. We had 3 CMGs in a little over a year come and go. Eventually, I said - "What good is a contract if one party can change it anytime they want to?"



This is the state of EM today.

One of my colleagues once mentioned to me how he got canned at his prior job. Guy was working a night shift, had a patient with acute ischemic limb. His shop had cardiology taking ischemic limb call. He calls the on call doc for this, who refuses to take said patient to cath lab, and just has him put the patient on heparin. Leg is pulseless and in bad shape. The hospitalist is blowing a gasket about admitting this patient and sitting on him and his ischemic leg, recommends transfer somewhere where there is a vascular doc who'll actually do something. EP agrees, ships patient out to a tertiary center.

The cardiologist finds out what happens, is not happy about this, and tells hospital administration either the EP leaves or he leaves. Of course, EP gets canned, since the cardiologist brings money to the hospital.

 

[Groove]

I call tertiary pediatric hospitals once a year or so and run a case by them. They love stuff like this and are very helpful. I definitely would help another ER doctor from an outside hospital. It's extremely low risk but fosters a sense of camaraderie. In the last 50yrs , how many successful legal suits have come from this? Can't think of any........


What I won't do though is be the "consult" for an NP/PA at an outlying facility. I don't trust their clinical judgement or skills. I have no clue if what they're telling me over the phone is accurate. I automatically accept the patient and assess them myself or have them call their medical director.

Same.

Oh, that reminds me of a related case I had one time a couple years out of residency with a pediatric pt who came in with vague abdominal discomfort on a Friday with cc N-V-D. Kid gets worked up, is tolerating PO. He really had a non worrisome exam. I had him hopping on his feet and eating a popsicle. Normal vitals. He had totally normal labs and no leukocytosis or traditional left shift but he had an isolated bandemia of like....15% bands. That's it. I had never had an isolated bandemia with nothing else and I was scratching my head trying to figure out whether this kid needed any further work up or not. I called the local pediatric tertiary care center and can't remember if I got peds hematology or if it was the ER doc (pediatrician). I discuss the case with them, they recommended no further work up and it sounded like something they would send home which made me feel better. I had a long talk with the mom about return precautions and discharged the kid. I went on a weekend vacation trip and all I could think about was that bandemia and kept worrying if the kid was ok or not. I finally called the mom on Sunday. She told me that he started vomiting again and she took him to the pediatric hospital on Saturday. His sx improved and he got discharged from the ER. He started vomiting again on Sunday with more abdominal pain and when she took him back to the pediatric ER, he got admitted for perforated appendicitis. Luckily, the mom was very understanding and not litigation minded. Kid turned out fine. Lesson learned from that case...beware an isolated bandemia!

 

[RuralEDDoc]

Specialists. It's very easy and I did it every now and again when I as moonlighting as a resident in an ER out in the middle of nowhere. These are people that are on call at the tertiary care center and, in general, were always happy to help. In fact, they were even more happy that it was something that wasn't going to have to be transferred.

I've never been called for help with a case in the ED, but if I did I would have no problem giving advice over the phone. You guys are harsh. It's a recorded line, all you have to do is say that you're limited in your ability to advise given that you can't examine the pt but given his or her description of the case, I would recommend x, y, z. It's not your patient, it's their patient. You're not managing them, he or she is. Just imagine how you'd feel if the pt had a bad outcome or died and it was because you failed to give advice for a struggling new doc who tried to call you for assistance and you wouldn't give it. If he puts your name down, so what? No jury in the world would find you at fault in a case like that.

Anyway, consulting the tertiary care center is easy and I never had a problem with it way back then. Cards, GI, nephrology, peds....all were very helpful. It's a resource that most new docs working in a small, sleepy, rural ER forget that they have available to them.

Not harsh. And I wouldn’t hang up the phone on them. I’d just tell them to call their medical director who should know their system well and help them navigate it. Just a different approach.


For the OP:
1. Meet your nurses at the beginning of your shift and at every shift change. The difference in information flow from a nurse you haven’t met to one you have is incredible.
2. Stay in contact with the charge nurse. He or she will know the system much better than you and should be able to help resolve issues and overcome barriers.
3. Initiate transfer early for patients that you know need transfer. Transport can take many hours to set up, to the detriment of the patient.
4. Really learn and understand what needs an emergency MRI. It’s not many things. Save yourself and your ED a lot of trouble and don’t order non emergent MRIs. Especially if you have to transfer to get that non emergent MRI.
5. When you get overwhelmed, stop and remember that your primary objective is to manage sick patients. Fall back on that and reprioritize as needed when things get crazy.

 

[RoyBasch]

1.) The utilization of specialists in academic/residency programs is very different than the community. Pretty much the only reason a specialist comes to evaluate a patient emergently in the ER in the community is to take the patient immediately to a procedure, or to evaluate for this with high probability.

2.)In the same vein as above, many things you were taught are "right this second" emergencies that require specialists' input, are not. More typically you will talk to the specialist on the phone (or not) and either admit the patient to a hospitalist and specialist will consult the next morning, or the patient will go home and follow up in the specialists office urgently. It's hard to give you a list of this because its going to vary by the actual doctors and community in question, but suffice to say get used to the fact it will be very different.

3.)minimize procedures, they are time sinks. Many do not have to be done immediately. Better to admit and have IR do it, or do something like an IO or call PICC team than do a CVC.

4.)If you have a question but no specialist on call, do not curb-side your EM partner, do not call the random ER and request to talk to the ER doc of a bigger hospital as some people have implied above.

The formal way to do this is to call the regional academic tertiary care transfer center and request to speak to their specialist on call. Sometimes they may want the patient transferred so they can evaluate, if so, great. Sometimes they will just give you some over-the-phone guidance and set up close follow up, which is good to. Either way, now you have a dispo. I find this option particularly helpful for pediatric specialty issues as pediatric specialists are fairly hard to come-by in most community hospitals.