First Attending shift jitters

[otacon88]

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I know this thread is seen all the time, but just thought I'd make another new thread. My first shift is tomorrow, fresh out of residency, and I'm scared sh*tless. Couldn't sleep the past few nights. My other colleagues who have started are already telling me stories of they see crazy stuff everyday that we didn't see in residency.

I know it happens to everyone, just have to stay calm, get through it.

What are some of the best resources you guys have used to help you on a shift? I currently have Pepid on browser and am thinking about getting EMRA pressordex, seems like a good app.

Any other advice would be greatly appreciated!

 

[goodoldalky]

There's really nothing that can remove this feeling, to be honest. Although I will say the fact that you feel this way is a good sign, those nerves are what keep you sharp. Just realize that you're well trained, you're ready to go, and in all likelihood you will have someone you can ask if you get into a tight spot and aren't sure what to do (colleague if double coverage, residency co-grad, old attending). And also rest assured that if you're not sure what to do, others probably wouldn't be sure either. And when push comes to shove, 1. Do what is best for the patient, and 2. Do what is going to allow yourself to sleep at night when you go home from your shift. You'll be alright.

 

[Hair Police]

Just to add on, these feelings are normal. My PD told me I could call him if I had any problems or wanted to run a patient past him. Nobody graduates having seen or managed everything.

PressorDex, EMRA abx guide, and a Peds resus card are my ED-EDCs. Use EMRA multiple times a shift, PressorDex is good for rarer but more critical patients. Peds card because we don't see many and I need a VS reference.

 

[Birdstrike]

I know this thread is seen all the time, but just thought I'd make another new thread. My first shift is tomorrow, fresh out of residency, and I'm scared sh*tless. Couldn't sleep the past few nights. My other colleagues who have started are already telling me stories of they see crazy stuff everyday that we didn't see in residency.

I know it happens to everyone, just have to stay calm, get through it.

What are some of the best resources you guys have used to help you on a shift? I currently have Pepid on browser and am thinking about getting EMRA pressordex, seems like a good app.

Any other advice would be greatly appreciated!

The minute you get moving during this shift it will ease. Just remember, most of it is easy stuff you could handle backwards and forward in your sleep. For the few tough cases, your training will kick in. Go back to ABCs and basic protocols and your training. For tougher diagnostic decisions, just keep this in your back pocket: In residency you had that one attending who refused to miss stuff, "Dr X." When in doubt, think, "What would Dr X do?" Then do it. A few people may get a test or two that turn out to be negative. They'll live.

Also, most likely you'll be not be working single coverage. Don't be afraid to run things by the older docs at your new job, "Hey, just curious what would do with this?" You're not a resident anymore but none of us are (or should be) too big for a curbside consult. They know you're green. Don't be afraid to ask.

Remember, it's normal to have a drop in confidence with an increase in responsibility. The only cure is time and experience. Confidence increases rapidly with each day for the first 6 months to a year, after finishing residency.

Bottom line. You'll be fine. The anticipation is usually worse than the reality. The waiting is the hardest thing.

Good luck.

 

[otacon88]

thanks for the replies guys. I agree the anticipation is the worst...i just want to get my first shift over with!

I think my biggest fear is going into the community after coming from a level 1 academic facility with a resident service for every single department. I know things are wayyyy different in the community, and i know the majority of it is getting used to how the new system works, but I'm still scared about the things that I didn't get to do much or at all during residency but that I will be expected to do now.

 

[Angry Birds]

It may be too late for this, but have you considered doing a shadow shift? I basically came in a day early during the medical director's shift, and I told him I'd see all the patients and for him to chill in the ED call room until and unless I needed his help. He stayed for four hours and then said "you got this, great job" and walked off, letting me get paid for half the shift. Anyways, that's a nice way to transition to flying solo.

The other thing is that you could request working double coverage for a few shifts, if your shop has double coverage (usually during evening shifts).

But really, this is all psychological. You'll be fine.

You can always call your colleagues on shift for help and run cases by them.

 

[dotcb]

You'll settle in pretty quickly, and it'll be like riding a bicycle. The first year or two is a pretty steep learning curve, like doing a mini fellowship in customer service, collegiality, and documentation. The medicine will be the least challenging part. Be a little conservative, trust your instincts, you'll be fine.

 

[Apollyon]

You'll settle in pretty quickly, and it'll be like riding a bicycle.

Yeah - when you fall off, it hurts!

 

[b-real]

New attending here x 1 month. Had the same apprehension as the OP, but as birdstrike says, the feeling goes away quickly. The one thing I would add is that if it takes more than a few seconds to talk yourself out of something, just do it. You'll sleep much better at night without having lingering doubts.

 

[Birdstrike]

The first year or two is ...like doing a mini fellowship in customer service, collegiality, and documentation.

A mini fellowship in customer service, collegiality and documentation? Have you looked into performing this as enhanced interrogation techniques on ISIS hold-outs? Now that waterboarding is no longer PC, you may be onto something big. Just sayin'.

 

[Tenk]

Uptodate is by far the best resource because it literally has everything you could ever want to know about anything (and it has its own app). Other than that pedistat is a good app for crashing kids.

I still remember the first patient I discharged on my own. I read the chart over like 3 times for a simple lac. Good times.

Just take it one patient at a time. If you're double coverage, ask your colleague. If you're single coverage, you always have a phone a friend at your home institution 24/7. I made a few calls my first few months but eventually you gain confidence just like in residency.

Do well!

 

[deleted547339]

Did you moonlight?

 

[Groove]

If you moonlighted in residency, it's no different than picking up a shift at a new ED. If not, don't sweat it... you got this! After you start seeing pt's, you will probably find yourself going into auto-pilot. As for apps, I use pepid, emra abx guide, epocrates, and have a personal uptodate account that I use when needed at work.

The best thing you can do for yourself starting out is get familiarized with all the ED specific metrics that you will be judged going forward by your dir and hospital administration. Most start out thinking it's all about pt care and that everyone is focused on how well you are managing pts. While this is true to some degree (% of your charts will prob be reviewed by med dir during your first 3 months or so...), you probably manage pts just fine. You want to get a grasp on all the tricks of the EMR and the ED to make your metrics look good as quickly as possible, while having as few pt complaints as possible. The concept of provider and ED metrics along with an increased focus on pt satisfaction (AIDET, etc..), documentation, etc.. can be discombobulating when coming out of residency in a pure EM clinical mindset. As someone else said, the medicine is the easy part...

Relax though, you'll be fine.

 

[Vandalia]

It is like football, once you get hit the first time everything slows down and calms down. (Unfortunately, in EM, that can quite literally be true.)

I will disagree a bit in that I would not worry too much about the finer details for the first month or so. Get comfortable first, then you can worry about the metrics and such.

 

[dav86]

Been an attending for a month and I agree with the above. The transition is difficult but not as bad as I thought. I did about 15 moonlighting shifts at a 50k volume ED always double covered and about 30 FT shifts. Even with that experience it has still been hard. I have learned a lot and see something new every day. Not having the sub specialist coverage can be difficult but you know more than you think. I think you should focus on the medicine to start and let the metric, customer satisfaction stuff come. I use uptodate daily and curbside consult all the time. Sometimes for medicine but most of the time its just system based issues (consultants, who admits what, transfers, etc.). I have my first overnight shift coming up in two days, five hours of solo physician coverage and two hours of total solo coverage, so I am a little nervous, but rarely are ppl coming in needing something in the next min, take a deep breath and remember ABCs and everything should work out. I love it but every shift I come home exhausted. I am hoping it gets better with time.

 

[Arcan57]

It's important to learn what metrics are important and how to meet them, but despite the general tone of this board it's pretty rare to get fired for being slow as a new grad. Quality concerns are a real issue in every system and a far more common cause of termination. One thing to keep crystal clear in your mind is that regardless of the 3-5 priorities that the hospital, your director, and your group want you to focus on is that nobody is going to use your superior metrics to defend you if a case goes bad. If you find that you can't maintain patient safety and meet the goals set for you, it's always the better choice to prioritize patient safety. It's much easier to find another job if you have a clean license and medmal hx.

Despite the above, there are a lot of things going in your favor. People know that you're new and there is some allowance for that in a way there isn't for the docs they've trended over time. You're going to make mistakes and even in the absence of mistakes you're going to have patients that do poorly. The key is to show up for every shift prepared to deliver your 'A' game and to not make the same mistake multiple times. Be humble, listen to feedback, and remember that you've navigated more difficult hurdles than the jump to attending. Showing up regaling the nursing staff with tales about how late you stayed up partying the night before or repeatedly ignoring red flags in your assessment of common, usually benign complaints can sink you.

 

[shoal]

Great thread. The first 10 shifts or so are super hard. I went home and had trouble sleeping because I was always thinking about patient x with something like a rash that I sent home and perhaps I missed NEC fasc... Its been a little better lately as I'm only a little over a month into being an attending. I've ordered more questionable studies then previously but it as a new attending I feel overtesting is the norm and slowly roping it back in over the next few years will be the way to go.

Sent from my VS986 using Tapatalk

 

[Old_Mil]

I know this thread is seen all the time, but just thought I'd make another new thread. My first shift is tomorrow, fresh out of residency, and I'm scared sh*tless. Couldn't sleep the past few nights. My other colleagues who have started are already telling me stories of they see crazy stuff everyday that we didn't see in residency.

I know it happens to everyone, just have to stay calm, get through it.

What are some of the best resources you guys have used to help you on a shift? I currently have Pepid on browser and am thinking about getting EMRA pressordex, seems like a good app.

Any other advice would be greatly appreciated!

Read "Bouncebacks" if you haven't already.

Pepid, UpToDate, John Hopkins App, Visual DX, MDCalc (great website, wish they had an app), PediStat on the phone.

Ron Walls Airway Card close at hand.

CYA with the documentation.

Trust your Spidey sense.

Make friends in the nursing staff early and often. Life is very good if they have your back and you have theirs.

You'll do just fine. You'll probably even find that the diagnosing/treating is the easiest part of it. What's hard is dealing with consultants, hospitalists, administration, IT folks, lawyers, legislatures, bureaucrats, patients and families.

 

[otacon88]

Thanks for all the replies guys. Well - I survived my first 4 shifts. Definitely rough, but i feel it's getting better and better each shift.

I feel like although I'm being conservative and ordering a lot of tests, i'm still discharging a lot of people.

For example i've discharged more chest painers than admitted, and coming from an academic institution we admitted even the 21 y/o with chest pain. Of course all the d/c's are low risk, no hx of CAD, and no concerning signs (risk stratified using HEART score on all of them).

Is that normal? I also give them cardiology f/u, but I don't actually set them up to get scheduled for an echo/stress test or appt with the Cardiologist - is this something I need to be doing as well?

 

[Birdstrike]

Thanks for all the replies guys. Well - I survived my first 4 shifts. Definitely rough, but i feel it's getting better and better each shift.

I feel like although I'm being conservative and ordering a lot of tests, i'm still discharging a lot of people.

For example i've discharged more chest painers than admitted, and coming from an academic institution we admitted even the 21 y/o with chest pain. Of course all the d/c's are low risk, no hx of CAD, and no concerning signs (risk stratified using HEART score on all of them).

Is that normal? I also give them cardiology f/u, but I don't actually set them up to get scheduled for an echo/stress test or appt with the Cardiologist - is this something I need to be doing as well?

Just do what you think is right for each patient, and it probably is.

 

[Old_Mil]

Congratulations and welcome to attendinghood...or attendingdom...or whatever you want to call it.

My personal practice pattern is to either stress a chest pain I am going to discharge in the ED or to discharge them with an outpatient stress test scheduled in the next 48-72 hours.. This way I know that I am not putting them in a situation where they either call the cardiologists office and are offered an appointment in two months, or they decide not to call at all. A "failure to refer" lawsuit is a real thing, a friend of mine is fighting one of those right now.

There is a EM text called Harwood-Nuss.. The first handful of chapters are titled "high risk chief complaints.“. I always think twice before sending one of those home.