First time attending Jitters - how nervous were you?

[cyanide12345678]

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Graduating pgy3 here. Getting somewhat anxious of being on my own. I don't get it, I've moonlighted for the last 10 months at least 2 shifts a month and have felt comfortable with it, but suddenly this feels different. Theoretically the volume of my job isn't terrible either (20k volume with 24 hr physician and 12 he MLP coverage), I mean how bad could that be

So what was it like for you guys starting off on your own? Any words of wisdom?

 

[thegenius]

Graduating pgy3 here. Getting somewhat anxious of being on my own. I don't get it, I've moonlighted for the last 10 months at least 2 shifts a month and have felt comfortable with it, but suddenly this feels different. Theoretically the volume of my job isn't terrible either (20k volume with 24 hr physician and 12 he MLP coverage), I mean how bad could that be

So what was it like for you guys starting off on your own? Any words of wisdom?

Be conservative....expect to do a lot of work ups. That is the right thing to do. You really don’t see all that much pathology in residency and you never really have to make decisions under pressure.

You won’t have a problem with the real sickies. In fact you are prob better at taking care of them than those who have been out of residency for 10-15 years. It’s the marginal cases where experience really matters.

You’ll do great!!!

 

[WildcatS11]

Be conservative....expect to do a lot of work ups. That is the right thing to do. You really don’t see all that much pathology in residency and you never really have to make decisions under pressure.

You won’t have a problem with the real sickies. In fact you are prob better at taking care of them than those who have been out of residency for 10-15 years. It’s the marginal cases where experience really matters.

You’ll do great!!!

You never had to make decisions under pressure in residency? That seems... odd. Also, I saw nothing but pathology in residency.

That being said, I totally agree with the rest of your post. Do the workups you think are questionable. Learn from the cases that confused you, or your misses/near misses. You WILL have some misses, and that's OK. Try to be conservative your first 1-2 years out. (note - I am still a junior attending, so grain of salt).

 

[gamerEMdoc]

You really don’t see all that much pathology in residency and you never really have to make decisions under pressure.

That is not my experience.

 

[thegenius]

You never had to make decisions under pressure in residency? That seems... odd. Also, I saw nothing but pathology in residency.

That being said, I totally agree with the rest of your post. Do the workups you think are questionable. Learn from the cases that confused you, or your misses/near misses. You WILL have some misses, and that's OK. Try to be conservative your first 1-2 years out. (note - I am still a junior attending, so grain of salt).

Sorry..I mean to write frequency of pathology. For instance, it was rare that I saw stable(ish) monomorphic VT. It just doesn't come in all that often. Not during residency, and not now. I've been out for 5 years. I probably get 2 a year. It's just not common.

The only thing you do, for the most part, is see the sick people in residency. But the breadth and nuisance of sickness is vast and I see stuff today, 5 years out, that I have never seen before. That's what I meant.

You'll know what to do with a HR 140, BP 60/30. Or HR 26 and a BP 60/30. You know they are critically ill and you resuscitate them.

However...I do believe that making unilateral decisions under pressure with no oversight in residency is rare. your attending, or senior resident, is always there and you subconsciously know that your decision is not final. There is a world of difference when everybody looks at YOU for the final say instead of someone higher than you.

 

[thegenius]

You never had to make decisions under pressure in residency? That seems... odd. Also, I saw nothing but pathology in residency.

The pressure you have as an attending is vastly more pronounced than the pressure you had as a resident.

 

[gamerEMdoc]

Sorry..I mean to write frequency of pathology. For instance, it was rare that I saw stable(ish) monomorphic VT. It just doesn't come in all that often. Not during residency, and not now. I've been out for 5 years. I probably get 2 a year. It's just not common.

The only thing you do, for the most part, is see the sick people in residency. But the breadth and nuisance of sickness is vast and I see stuff today, 5 years out, that I have never seen before. That's what I meant.

You'll know what to do with a HR 140, BP 60/30. Or HR 26 and a BP 60/30. You know they are critically ill and you resuscitate them.

However...I do believe that making unilateral decisions under pressure with no oversight in residency is rare. your attending, or senior resident, is always there and you subconsciously know that your decision is not final. There is a world of difference when everybody looks at YOU for the final say instead of someone higher than you.

Yeah I definitely agree with that. Sick people are easy. Fast track and straight forward cases are easy. But the weird situations you get in, the bizarre cases, there's a lot of decisions that get made with little info and less time. And having to be the final say definitely can be tough to cope with. No doubt.

 

[scummie]

Wear brown scrubs and bring extra.

If you’re talking yourself out of something, you should do it.

Your job as a new attending is not to move the meat, but to treat every patient like how you’d want your family member to be treated. You should be conservative, with higher CT and admission rates.

You’re going to find yourself challenged with a difficult patient. Know your philosophy and stick to it. At the end of the day, you need to be able to sleep at night.

Follow up on your patients. Call them. See what the intensivist does. See if they do get admitted.

 

[RoyBasch]

I'm not sure if you will find this comment helpful or not, because I can't reassure you and say it's not anxiety provoking. That being said, perhaps you will find it reassuring to know that other people in the same position have felt the same way.

It's a very difficult job, transitioning to being an attending in the ER is very tough. I didn't feel good about it for a long time. How long will depend on you. I think for everybody who isn't very arrogant and truly realizes what's at stake it's at least 3-6 months, but for some people it's years. Just know that at some point going to work will feel "normal" and you won't really start thinking about it until you're already walking into the shop and it will someday color less of your life outside of work.

I think the people who are good and who care have these feelings. Have worked with 100+ residents, I can tell you the one's who do not have these feelings usually are simply supercilious and I have heard through the grape-vine/noticed significant clinical errors in the early months and years of their practice.

As often pointed out on this board, emergency medicine is a classic example of the "Dunning-Kruger Effect." Many under-confident senior residents and new grads are simply sitting at that large nadir in the confidence vs. ability curve despite having advanced and progressing knowledge and ability.

Learning doesn't (and shouldn't)have to stop just because residency is over. Treat every case with the enthusiasm you had for your first case of intern year and the experience that you had when you saw your last case senior year. You can still learn to finesse your approaches and improve your quality and efficiency as time goes on as long as you are willing to honestly assess your outcomes and workups as an attending--particularly if you can acknowledge errors or inefficiencies in your own practice.

 

[Zebra Hunter]

I'm now 1 year out from residency. I've found that the thing that has changed my practice the most (by far) is chart review.

Hopefully you have an EMR where it is easy to look up the patients you have previously seen. I'm able to review all patients that have bounced back. So about every 4-5 days I look through old patients to see if any of them had a return visit. I have found that my bounceback rate over an 8 day span is somewhere around 4-5% within our large hospital system. If one of my patients has returned, I see if there is anything I missed on the workup or my documentation that would have been important to include. Your colleagues will almost never tell you about a bounceback, even if it was bad, so don't rely on them. I've significantly improved my ability to predict the patients that have a high probability of outpatient failure. It has also significantly humbled me and has made me more likely to more thoroughly re-assess a situation if the patient still complains of an issue following treatment and evaluation. I also spend way more time managing expectations, discussing the probability of treatment failure, discussing the possibility of imaging and labs missing acute issues early on in the disease process and the importance of returning or at least early re-assessment if things change, and giving very specific/uncomplicated follow-up instructions. Also, don't be afraid to tack on imaging, or labs, observe them for another hour or two, or even to admit for obs if after all of your evaluation sending the patient home makes you nervous.

 

[RoyBasch]

I have found that my bounceback rate over an 8 day span is somewhere around 4-5% within our large hospital system. If one of my patients has returned, I see if there is anything I missed on the workup or my documentation that would have been important to include. Your colleagues will almost never tell you about a bounceback, even if it was bad, so don't rely on them. I've significantly improved my ability to predict the patients that have a high probability of outpatient failure.

Although I'm a big believer in chart review as a way to QA your own practice and continue to learn (in fact I recommended it as such in a different thread), you don't need to view every bounce back as a "failure."

I truly believe some patients are low risk and will probably be better served trying to go home and manage outpatient and return if that doesn't succeed. Especially in cases where the outpatient failure results in a more indolent decline rather than sudden decompensation. For example, I think a lot of borderline cellulitis can and should attempt outpt therapy with PO ABx (again assuming they aren't sick, septic, lots of comorbidities blah blah blah). The only way to have no bouncebacks in these cases are to admit all of them, but I feel you are ultimately doing a disservice by introducing more powerful big gun IV Antibiotics into the world and introducing patients to iatrogenic harms and nosocomial issues.

Another example are low risk patients with abdominal pain. I think if their exam is unimpressive and the history is not suggestive of a serious or important diagnosis, it is ok to hold of on imaging and dc with strict return precautions. Of course we all know of people with epigastric tenderness or some other atypical history and exam that wound up having an appendicitis; however, again, you will be massively over-imaging and over-admitting patients and have lots of negative scans if you don't manage any of these patients expectantly. Again the feared complication--intraabdominal infection--does not result in sudden decompensation, patient's don't go from "appy brewing" to "septic shock and peritonitis" immediately, its a gradual process and so I think it is ok for the patients to return urgently if they are not improving in 12-48 hours.

One case where I agree bouncebacks are sub optimal is where the disease the patient is at risk for can result in sudden death or decompensation so fast the patient cannot reasonably even seek or return to care. The quintessential example is admitting chest pain patients with "negative" workups in the ER but age and risk factors. The concern is if they do have symptomatic coronary artery disease (but no evidence of infarction in the ER), they may go home and have a STEMI or malignant tachydysrhythmia, which would kill or incapacitate them so fast they can't even call 911 and have the opportunity to bounceback, so I agree conservative disposition is a must in these cases.

Again how you frame these conversations and expectations with patients is key. Discussion of risk, return precautions, and in very low risk but not no-risk situations perhaps doing informed decision making with appropriately selected patients are important. Taking into mind holistically the patient's real social situation (not the tobacco, ethanol, drugs social history) but what are you actually sending the patient home TO is also important with regards to disposition. That little old lady who lives alone who you are worried about a delayed head bleed, probably needs a more conservative disposition. Nobody is there to watch her, if she starts to get more confused or obtunded form a growing subdural, she may not have the insight to recognize her condition and follow her return precautions and dial 911 even if this process is occurring over a course of hours.

 

[Zebra Hunter]

Although I'm a big believer in chart review as a way to QA your own practice and continue to learn (in fact I recommended it as such in a different thread), you don't need to view every bounce back as a "failure."

I truly believe some patients are low risk and will probably be better served trying to go home and manage outpatient and return if that doesn't succeed. Especially in cases where the outpatient failure results in a more indolent decline rather than sudden decompensation. For example, I think a lot of borderline cellulitis can and should attempt outpt therapy with PO ABx (again assuming they aren't sick, septic, lots of comorbidities blah blah blah). The only way to have no bouncebacks in these cases are to admit all of them, but I feel you are ultimately doing a disservice by introducing more powerful big gun IV Antibiotics into the world and introducing patients to iatrogenic harms and nosocomial issues.

Another example are low risk patients with abdominal pain. I think if their exam is unimpressive and the history is not suggestive of a serious or important diagnosis, it is ok to hold of on imaging and dc with strict return precautions. Of course we all know of people with epigastric tenderness or some other atypical history and exam that wound up having an appendicitis; however, again, you will be massively over-imaging and over-admitting patients and have lots of negative scans if you don't manage any of these patients expectantly. Again the feared complication--intraabdominal infection--does not result in sudden decompensation, patient's don't go from "appy brewing" to "septic shock and peritonitis" immediately, its a gradual process and so I think it is ok for the patients to return urgently if they are not improving in 12-48 hours.

One case where I agree bouncebacks are sub optimal is where the disease the patient is at risk for can result in sudden death or decompensation so fast the patient cannot reasonably even seek or return to care. The quintessential example is admitting chest pain patients with "negative" workups in the ER but age and risk factors. The concern is if they do have symptomatic coronary artery disease (but no evidence of infarction in the ER), they may go home and have a STEMI or malignant tachydysrhythmia, which would kill or incapacitate them so fast they can't even call 911 and have the opportunity to bounceback, so I agree conservative disposition is a must in these cases.

Again how you frame these conversations and expectations with patients is key. Discussion of risk, return precautions, and in very low risk but not no-risk situations perhaps doing informed decision making with appropriately selected patients are important. Taking into mind holistically the patient's real social situation (not the tobacco, ethanol, drugs social history) but what are you actually sending the patient home TO is also important with regards to disposition. That little old lady who lives alone who you are worried about a delayed head bleed, probably needs a more conservative disposition. Nobody is there to watch her, if she starts to get more confused or obtunded form a growing subdural, she may not have the insight to recognize her condition and follow her return precautions and dial 911 even if this process is occurring over a course of hours.

Never implied all bouncebacks are "failures". I'm perfectly comfortable with my bounceback rate of 4-5% at 8 days (this is only within my hospital system, I'm sure it's probably higher than that overall). National average is around 8% for first 3 days after ED discharge, and 20% at 30 days. Most of my bouncebacks are BS like 20 yo musculoskeletal chest pain, or dental pain, or non-emergent rash. I also have one of the lower admission rates in my group. The bouncebacks I care about are the ones requiring admission where there was something I could have foreseen on initial visit to prevent decompensation. Oftentimes there is something there, however, frequently there isn't, but it is important to review these cases in order to identify practice patterns that might need a slight change.

 

[RoyBasch]

National average is around 8% for first 3 days after ED discharge, and 20% at 30 days.

Wow I never knew the actual national statistics, and that they were that high. Then again it does seem like some days all I'm seeing are ER bouncebacks, inpt dc bouncebacks, and pt's just dc'd from other hospitals who drive straight to our hospital for a "second opinion," so maybe not so surprising.

 

[GonnaBeADoc2222]

Go at the pace that is comfortable for you. This is especially true if you are non-RVU based. 1.5 pph is very reasonable for a brand new attending.

Learn to moderate your flow. There is no reason to go above 2-2.2 pph unless multiple sick patients arrive at the same time. Most people aren't that sick and can wait despite what management tells you. Sign your charts in real time. Try your HARDEST not to bring documentation home. This will be difficult at first but you will get better at it as time goes on. I typically have 3-4 unsigned charts at the end of a shift and complete them at the beginning of my next shift (takes 10-15 mins) before seeing any new patients (I will put in orders for them though to get the ball rolling).

If you're working with another attending or two, try to match their speed if they're going slow. No reason for them to coast at 1.5 pph while you get stuck seeing 3 pph. You will have a seemingly insatiable urge to click on a patient as soon as they arrive. This was conditioned into you during residency by the corporate-healthcare complex. Resist it.

Learn which nurses you can trust and which are idiots. Do what you need to do for your patients and yourself and ignore their "can't you just order this and not this", "why is this patient being admitted they want to be discharged", "why is this person being discharged they want to be admitted". "can't we just put a bag on the febrile neonate and not cath them?" etc etc. A lot of them are lazy and looking for the easy way out. Some are stellar and will be your best resource as a young attending.

Phone consults don't mean ANYTHING. Do not listen to consultants who tell you to discharge when you know the answer is to admit. Transfer patients to the tertiary center if the community consultant is being a jack***. You have to do what's right for the patient.

If you're working for a CMG or a for-profit hospital (or the worst scenario - a CMG contracted w a for-profit hospital), get ready for them to gaslight you and f*** you at every step of the way. They may try to put you on single coverage nights before it's appropriate, or not fill call outs and try to force you into single coverage. They loveeee naive attendings who go full steam for their entire shift and then have 2-3 hours of documentation left over. It's free labor for them. Don't stand for it,.

If working for a CMG, get ready for craaaaaaaaapyyy midlevels. They will literally hire anyone. Patients will be under-worked up, over-worked up, consults called when unnecessary, wrong abx prescribed, etc etc. Do not trust them. 1-2 will be great.

 

[RoyBasch]

Go at the pace that is comfortable for you. This is especially true if you are non-RVU based. 1.5 pph is very reasonable for a brand new attending.

Learn to moderate your flow. There is no reason to go above 2-2.2 pph unless multiple sick patients arrive at the same time. Most people aren't that sick and can wait despite what management tells you. Sign your charts in real time. Try your HARDEST not to bring documentation home. This will be difficult at first but you will get better at it as time goes on. I typically have 3-4 unsigned charts at the end of a shift and complete them at the beginning of my next shift (takes 10-15 mins) before seeing any new patients (I will put in orders for them though to get the ball rolling).

If you're working with another attending or two, try to match their speed if they're going slow. No reason for them to coast at 1.5 pph while you get stuck seeing 3 pph. You will have a seemingly insatiable urge to click on a patient as soon as they arrive. This was conditioned into you during residency by the corporate-healthcare complex. Resist it.

Learn which nurses you can trust and which are idiots. Do what you need to do for your patients and yourself and ignore their "can't you just order this and not this", "why is this patient being admitted they want to be discharged", "why is this person being discharged they want to be admitted". "can't we just put a bag on the febrile neonate and not cath them?" etc etc. A lot of them are lazy and looking for the easy way out. Some are stellar and will be your best resource as a young attending.

Phone consults don't mean ANYTHING. Do not listen to consultants who tell you to discharge when you know the answer is to admit. Transfer patients to the tertiary center if the community consultant is being a jack***. You have to do what's right for the patient.

If you're working for a CMG or a for-profit hospital (or the worst scenario - a CMG contracted w a for-profit hospital), get ready for them to gaslight you and f*** you at every step of the way. They may try to put you on single coverage nights before it's appropriate, or not fill call outs and try to force you into single coverage. They loveeee naive attendings who go full steam for their entire shift and then have 2-3 hours of documentation left over. It's free labor for them. Don't stand for it,.

If working for a CMG, get ready for craaaaaaaaapyyy midlevels. They will literally hire anyone. Patients will be under-worked up, over-worked up, consults called when unnecessary, wrong abx prescribed, etc etc. Do not trust them. 1-2 will be great.

New grads listen to this, he speaks the truth. Especially on phone consults from sheit consultants, you can wipe your ass with them.

 

[scummie]

If you're working with another attending or two, try to match their speed if they're going slow. No reason for them to coast at 1.5 pph while you get stuck seeing 3 pph. You will have a seemingly insatiable urge to click on a patient as soon as they arrive. This was conditioned into you during residency by the corporate-healthcare complex. Resist it.

...

If you're working for a CMG or a for-profit hospital (or the worst scenario - a CMG contracted w a for-profit hospital), get ready for them to gaslight you and f*** you at every step of the way. They may try to put you on single coverage nights before it's appropriate, or not fill call outs and try to force you into single coverage. They loveeee naive attendings who go full steam for their entire shift and then have 2-3 hours of documentation left over. It's free labor for them. Don't stand for it,.

Basically the whole post is gospel, but these bolded parts are especially true.

 

[Birdstrike]

Graduating pgy3 here. Getting somewhat anxious of being on my own. I don't get it, I've moonlighted for the last 10 months at least 2 shifts a month and have felt comfortable with it, but suddenly this feels different. Theoretically the volume of my job isn't terrible either (20k volume with 24 hr physician and 12 he MLP coverage), I mean how bad could that be

So what was it like for you guys starting off on your own? Any words of wisdom?

Just know that new attending jitters and uncertainty are normal. It will go away quicker than you think it will.

 

[NYEMMED]

Go at the pace that is comfortable for you. This is especially true if you are non-RVU based. 1.5 pph is very reasonable for a brand new attending.

Learn to moderate your flow. There is no reason to go above 2-2.2 pph unless multiple sick patients arrive at the same time. Most people aren't that sick and can wait despite what management tells you. Sign your charts in real time. Try your HARDEST not to bring documentation home. This will be difficult at first but you will get better at it as time goes on. I typically have 3-4 unsigned charts at the end of a shift and complete them at the beginning of my next shift (takes 10-15 mins) before seeing any new patients (I will put in orders for them though to get the ball rolling).

If you're working with another attending or two, try to match their speed if they're going slow. No reason for them to coast at 1.5 pph while you get stuck seeing 3 pph. You will have a seemingly insatiable urge to click on a patient as soon as they arrive. This was conditioned into you during residency by the corporate-healthcare complex. Resist it.

Learn which nurses you can trust and which are idiots. Do what you need to do for your patients and yourself and ignore their "can't you just order this and not this", "why is this patient being admitted they want to be discharged", "why is this person being discharged they want to be admitted". "can't we just put a bag on the febrile neonate and not cath them?" etc etc. A lot of them are lazy and looking for the easy way out. Some are stellar and will be your best resource as a young attending.

Phone consults don't mean ANYTHING. Do not listen to consultants who tell you to discharge when you know the answer is to admit. Transfer patients to the tertiary center if the community consultant is being a jack***. You have to do what's right for the patient.

If you're working for a CMG or a for-profit hospital (or the worst scenario - a CMG contracted w a for-profit hospital), get ready for them to gaslight you and f*** you at every step of the way. They may try to put you on single coverage nights before it's appropriate, or not fill call outs and try to force you into single coverage. They loveeee naive attendings who go full steam for their entire shift and then have 2-3 hours of documentation left over. It's free labor for them. Don't stand for it,.

If working for a CMG, get ready for craaaaaaaaapyyy midlevels. They will literally hire anyone. Patients will be under-worked up, over-worked up, consults called when unnecessary, wrong abx prescribed, etc etc. Do not trust them. 1-2 will be great.

Love this.

You just summed up my last 3 years.

I would add, learn who the good midlevels are and who not to trust. If you are signing the midlevels charts (which CMGs love to make you do) you are responsible. For crappy midlevels, go see the patient at least briefly/unofficially (on higher risk patients/stories), make sure the story and plan matches.
Majority of bad/avoidable bounce backs I’ve seen were from “independent” midlevels

 

[Birdstrike]

As far as speed, there will always be a bell curve. There's always going to be a fastest and always a slowest. Most will be somewhere in between. You just don't want to the fastest or the slowest. Stay between the goalposts and you'll be fine, always.

 

[Birdstrike]

As for the new attending jitters, here's something that helped me on rare occasions. In residency, we had this guy who I'm going to call, "The Crusher." If you ever presented a case to him and hedged even slightly, he'd look at you stone faced through his downturned glasses, pause and say, "Just get the test." Every time. He didn't give a ****. Scan, x-ray, LP, culture, he didn't care. If you came in the ED with any complaint he was testing it. If you refused the test and he had to cancel it he cared even less, but he sure as hell was going to let the record show he ordered it. If there was 0.00000000000000000001% chance of you having a thing, he was going to prove, beyond a shadow of a doubt you didn't have it. And he wouldn't spend 1/1,000th of a second contemplating it. Gold standard test. Box checked. Bye. Next.

Among the residents we had this saying, "When in doubt, what would The Crusher do?' Just think of the zero-risk acceptance, medical-costs-be-damned approach. You can't and shouldn't follow it with every patient. But when in doubt, do what The Crusher would do.

I'm not saying you should practice this way. You shouldn't. And 99.9% of the time you're going to efficiently do what comes naturally. It sounds silly in retrospect, but falling back on, "What would Crusher do?" got me out of more than a few jams that first 6 months.

What would The Crusher do?
Get the test.

 

[Groove]

I'm now 1 year out from residency. I've found that the thing that has changed my practice the most (by far) is chart review.

Hopefully you have an EMR where it is easy to look up the patients you have previously seen. I'm able to review all patients that have bounced back. So about every 4-5 days I look through old patients to see if any of them had a return visit. I have found that my bounceback rate over an 8 day span is somewhere around 4-5% within our large hospital system. If one of my patients has returned, I see if there is anything I missed on the workup or my documentation that would have been important to include. Your colleagues will almost never tell you about a bounceback, even if it was bad, so don't rely on them. I've significantly improved my ability to predict the patients that have a high probability of outpatient failure. It has also significantly humbled me and has made me more likely to more thoroughly re-assess a situation if the patient still complains of an issue following treatment and evaluation. I also spend way more time managing expectations, discussing the probability of treatment failure, discussing the possibility of imaging and labs missing acute issues early on in the disease process and the importance of returning or at least early re-assessment if things change, and giving very specific/uncomplicated follow-up instructions. Also, don't be afraid to tack on imaging, or labs, observe them for another hour or two, or even to admit for obs if after all of your evaluation sending the patient home makes you nervous.

This is such a great habit to get into and I'm really glad to hear someone else does it in here. So valuable. Virtually all EMRs will have a reporting feature to generate reports on bouncebacks within 3 or 5 days, etc.. Ever since residency, I've generated this report on a monthly basis and reviewed my own bounce backs as well as others. I also keep a list of admitted patients (Easy to do in Epic and Cerner) that I deemed sick enough to be admitted and track their progress in the hospital to see what consultants thought, ultimate disposition, etc.. It doesn't take much time and it's really valuable over the long haul. I started this habit 10 years ago and still do it to this day. Sure, it can sometimes make you little more paranoid but I think ultimately makes you a better clinician in the long haul. I'm not the fastest in our group (2.2-2.3pph) and certainly not the slowest, but I have by far the lowest bounce backs out of anyone in our group. Now, to be fair, most bouncebacks are trivial...drug seekers, non compliant pt's, but every now and then you'll identify someone that probably should have stayed the first time. Even if it's not your patient, there's usually something to be learned. I actually enjoy running the damn thing. Maybe I snoop too much. I actually find them very interesting.

To the OP, regarding new attending jitters... I'm not much help there. I think I was in a minority. Maybe it was from all the moonlighting, etc.. I have no idea but I actually felt just fine coming right out of residency. You just have to keep in mind...there's really nothing that you haven't been trained to deal with at this point, you know? You're graduating from an EM RRC approved residency program and are probably better trained than 70% of the FP/IM physicians out there staffing most of these community EDs. Have some confidence in yourself. Even if you can't figure something out, you've got tons of resources available. You can always consult at your local hospital, consult the tertiary care center, consult a fellow attending. I'm extremely flattered when my colleagues run cases by me for my thoughts. I've had no problem doing the same in the past. The concept of never truly being alone probably hit me when I was moonlighting in a rural 17K single coverage ED out in the middle of nowhere as a PGY3. I always had a direct line to the tertiary care center 45 mins away and on occasion I'd call up GI, peds, hell even IM and run a case by them to get their thoughts. You're never truly alone. Always remember that. You'll quickly realize just how well you've been trained as you get used to the flow in your new gig and realize "Hey! I've done all this a million times before...I know this!" Just have confidence in yourself.

 

[Tenk]

If you moonlighted a bunch you should have a fine transition. If you are unsure of ordering a test, just order it. If you are unsure how someone will do just sit on them.

Also, buy your staff pizza when you first start working there a few times.

 

[Groove]

Also, you're going to make mistakes and you're going to miss things. It doesn't make you poorly trained, it just makes you human. You'll have a few of those cases when you're newly out where you're just not quite sure what to do with them and/or you worry after you sent them home. If you're worried about them, give them a call the next day or two and check on them...there's nothing wrong with that.

I remember a peds case I had one time not far out of residency where the CC was n/v/d, 8yo boy. Mother brought him in and thought he had food poisoning. VSS, work up relatively benign. No leukocytosis, no traditional left shift. Reassuring exam, absolutely no belly pain after multiple exams with all the traditional signs negative. Kid is eating a popsicle, jumping and running around the room. The only thing and I do mean the ONLY thing that bothered me on the work up was an isolated bandemia of 18-20K. Everything else was stone cold normal. I agonized over that bandemia because it just fundamentally bothered me. I worried about occult bacteremia/sepsis, infections, etc.. He was just so atypical for appendicitis and I really didn't want to scan him for no reason. So, I call up our local peds center and...hell, I think they put me in touch with a peds hematologist or something. We went over the case, the diff, and she reassured me that an isolated bandemia was nothing to worry about. I found some literature that equivocated about bandemias in these types of cases and some would argue to obs them for occult infection and others would argue that this was antiquated thinking and that there was no reason to worry about them as much as in times past... Regardless, I let the kid go home. Very responsible parent and she assured me that she would go to the ER at the first sign of worsening sx and have the kid re-evaluated within 48h.

It was a friday. I was leaving on a weekend vacation and the whole way there I ruminated about that bandemia. I called the mom on Sunday and lo and behold... She said the kid vomited again and she took him to the pediatric center. They worked him up and were not very impressed and sent him back home. (Saturday). Sun, he develops a fever and she took him back to the pediatric center again.... Perf'd appy. Luckily, kid did just fine and mom was really thankful for everything and appreciative that I was calling and concerned but it just goes to show...these things happen. In spite of your skills and experience and in spite of your best intentions, not everything is textbook and you'll have some cases like above.

I forget what my point was with this whole story... I suppose I'm trying to say that it's normal to have a few cases where you're not 100% sure about the diagnosis and/or the dispo. That's normal and don't beat yourself up if you occasionally miss something. Most of the times, the pt does just fine. If you are really worried about the pt, call them up a day or two after discharge and check on them. Even today, I'll do this on occasion. They are usually very appreciative to hear from their doc.

 

[MechEDoc]

What would The Crusher do?
Get the test.

Spend your patient's money, not your retirement.

UDS are useless, but they can sure help undermine a patient. Say a soccer mom didn't get their percs. They complain. You state the obvious (narcs weren't indicated, they were unreasonable) and their UDS shows THC, methamphetamine, and diacetylmorphine... Admin likely won't take that as seriously.

 

[deleted859535]

Protect yourself. Get the test if in doubt. Understand that you will be increasingly more comfortable in your own skin in the next year or two, and your workups will change. That's okay. You're not the first. You won't be the last.

 

[GonnaBeADoc2222]

If you moonlighted a bunch you should have a fine transition. If you are unsure of ordering a test, just order it. If you are unsure how someone will do just sit on them.

Also, buy your staff pizza when you first start working there a few times.

I don't bribe people to do their jobs. I document on the chart when they dont.

 

[Tenk]

I don't bribe people to do their jobs. I document on the chart when they dont.

You must be really popular with the staff.

It’s not bribing. Having the new guy buy lunch as a friendly gesture is a sign of camaraderie. But you do you. In the mean time I’ll be the guy everyone high fives and smiles at when I walk through the door like Maverick and Goose in Top Gun.

Also, it’s a good excuse to eat pizza.

 

[thegenius]

I've significantly improved my ability to predict the patients that have a high probability of outpatient failure. It has also significantly humbled me and has made me more likely to more thoroughly re-assess a situation if the patient still complains of an issue following treatment and evaluation. I also spend way more time managing expectations, discussing the probability of treatment failure, discussing the possibility of imaging and labs missing acute issues early on in the disease process and the importance of returning or at least early re-assessment if things change, and giving very specific/uncomplicated follow-up instructions.

Agree with that. You develop a good sense of who will do what you want them to do, and who won’t.

And I like the point about setting expectations. Every year that goes by, I increase the frequency of saying something like “our job is to make sure you are not going to die. I may not give you a diagnosis, but I’m gonna make sure your organs are working ok and that you aren’t going to become super sick or die in coming days to weeks.”

Most people seemingly get that. They might be upset, but they understand. You already know they are not sick. Some don’t need anything. But you order regular labs anyway just for them.

 

[thegenius]

Also, you're going to make mistakes and you're going to miss things. It doesn't make you poorly trained, it just makes you human. You'll have a few of those cases when you're newly out where you're just not quite sure what to do with them and/or you worry after you sent them home. If you're worried about them, give them a call the next day or two and check on them...there's nothing wrong with that.

I remember a peds case I had one time not far out of residency where the CC was n/v/d, 8yo boy. Mother brought him in and thought he had food poisoning. VSS, work up relatively benign. No leukocytosis, no traditional left shift. Reassuring exam, absolutely no belly pain after multiple exams with all the traditional signs negative. Kid is eating a popsicle, jumping and running around the room. The only thing and I do mean the ONLY thing that bothered me on the work up was an isolated bandemia of 18-20K. Everything else was stone cold normal. I agonized over that bandemia because it just fundamentally bothered me. I worried about occult bacteremia/sepsis, infections, etc.. He was just so atypical for appendicitis and I really didn't want to scan him for no reason. So, I call up our local peds center and...hell, I think they put me in touch with a peds hematologist or something. We went over the case, the diff, and she reassured me that an isolated bandemia was nothing to worry about. I found some literature that equivocated about bandemias in these types of cases and some would argue to obs them for occult infection and others would argue that this was antiquated thinking and that there was no reason to worry about them as much as in times past... Regardless, I let the kid go home. Very responsible parent and she assured me that she would go to the ER at the first sign of worsening sx and have the kid re-evaluated within 48h.

It was a friday. I was leaving on a weekend vacation and the whole way there I ruminated about that bandemia. I called the mom on Sunday and lo and behold... She said the kid vomited again and she took him to the pediatric center. They worked him up and were not very impressed and sent him back home. (Saturday). Sun, he develops a fever and she took him back to the pediatric center again.... Perf'd appy. Luckily, kid did just fine and mom was really thankful for everything and appreciative that I was calling and concerned but it just goes to show...these things happen. In spite of your skills and experience and in spite of your best intentions, not everything is textbook and you'll have some cases like above.

I forget what my point was with this whole story... I suppose I'm trying to say that it's normal to have a few cases where you're not 100% sure about the diagnosis and/or the dispo. That's normal and don't beat yourself up if you occasionally miss something. Most of the times, the pt does just fine. If you are really worried about the pt, call them up a day or two after discharge and check on them. Even today, I'll do this on occasion. They are usually very appreciative to hear from their doc.

I know you weren’t going there...but the care for that kid you had was just fine. I mean ****...if he was sucking on a popsickle and literally jumping up and down and having a grand old time, what are you going to do? Admit him and wait for something to change? He would be running up and down the halls in your hospital, spending 3K/day of insurance money or government tax money eating popsickles. He got sick 48 hours later. You made a good call man. It’s a 1/1000 case.

 

[thegenius]

You must be really popular with the staff.

It’s not bribing. Having the new guy buy lunch as a friendly gesture is a sign of camaraderie. But you do you. In the mean time I’ll be the guy everyone high fives and smiles at when I walk through the door like Maverick and Goose in Top Gun.

Also, it’s a good excuse to eat pizza.

At my part time job I fill the nurses candy drawer with $25 of chocolate and other goodies once/month. The staff loves it!!!!! It’s totally worth it.

 

[MechEDoc]

I don't bribe people to do their jobs. I document on the chart when they dont.

There is value in this. Everyone wants to be important, call the shots, and act real smart ("e.g. stupid doctor, I did what I know was right, heart of a nurse, experience, hurr, durr, etc.") until things go wrong and then you'll be hung out to dry. Expect professionalism and simply state how things unfolded (either in the chart or in personal notes*).

E.g. had a patient with a bad headache. Ordered fentanyl. Nurse said no. I still believed that fentanyl was the right choice. Left the order active. Eventually got the CT back -> bad pathology -> oops! "I'd be happy to give the fentanyl now". That patient sat in agony while you f-ed around. Want to question orders? Do so safely. We all make mistakes. Passive aggressive BS will leave you exposed.

I often keep personal notes of minor things. Saved my bacon once at a malignant site. Wildly toxic charge nurse decided to go after me. I talked it over with the medical director and proceeded review shift notes and explain how I would be happy to bring this to the nursing board to review her actions and licence. Nurse ratchet was an angel from that point on...

I also bring candy and food, small gestures go a long ways.

 

[Birdstrike]

Buying staff pizza, candy or doing other nice things shouldn’t be viewed as a weakness or butt kissing. I know it can feel that way sometimes. But not only are such things nice things to do, in general, you’ll get paid back times ten.

Supporting staff with axes to grind can make your life a hell of a lot easier or a lot harder. And there’s nothing worse than a passive aggressive nurse working to undermine you, or who’s simply putting attention elsewhere, when the going gets tough.

It’s a lot harder to be a passive aggressive jerk to someone that’s been nice to you. And a lot easier to save that negative energy for the guy who either ignores you or has an less positive attitude.

Rather than viewing it as a situation where you’re “serving your underlings” it makes more sense to view it as a situation where if you help them out today, they’re much more likely to go the extra mile for you when you’re in a jam. Since many docs tend to have more of the negative attitude, it doesn’t take a lot to stand out as one of “good ones” staff views worth helping as opposed to passively or actively resisting. For the cost of 2 large pizzas once a month, you’re likely to get paid much more than that back in the future.

 

[Groove]

I know you weren’t going there...but the care for that kid you had was just fine. I mean ****...if he was sucking on a popsickle and literally jumping up and down and having a grand old time, what are you going to do? Admit him and wait for something to change? He would be running up and down the halls in your hospital, spending 3K/day of insurance money or government tax money eating popsickles. He got sick 48 hours later. You made a good call man. It’s a 1/1000 case.

Hey, I appreciate it brother. I'm honestly perfectly fine with my care... I think we all just hate missing things, you know? The perfectionist in all of us! Thanks for the words though...

 

[betamale]

Not very. Mostly tired. I worked 26 shifts/month for 4 months prior to finishing training (moon lighting and training shifts).

 

[scummie]

Buying staff pizza, candy or doing other nice things shouldn’t be viewed as a weakness or butt kissing. I know it can feel that way sometimes. But not only are such things nice things to do, in general, you’ll get paid back times ten.

Supporting staff with axes to grind can make your life a hell of a lot easier or a lot harder. And there’s nothing worse than a passive aggressive nurse working to undermine you, or who’s simply putting attention elsewhere, when the going gets tough.

It’s a lot harder to be a passive aggressive jerk to someone that’s been nice to you. And a lot easier to save that negative energy for the guy who either ignores you or has an less positive attitude.

Rather than viewing it as a situation where you’re “serving your underlings” it makes more sense to view it as a situation where if you help them out today, they’re much more likely to go the extra mile for you when you’re in a jam. Since many docs tend to have more of the negative attitude, it doesn’t take a lot to stand out as one of “good ones” staff views worth helping as opposed to passively or actively resisting. For the cost of 2 large pizzas once a month, you’re likely to get paid much more than that back in the future.

Currently broke AF, but I do find please and thank you's go a long way. No one wants to work in a place where they feel like they have to walk on egg shells. Try to think of it as minimizing the collective group misery. Have found out with this strategy, the techs and nurses will grab me for sick people or odd EKGs instead of the other docs. The PA's will also give me some of their charts too. I also make it a point to thank the secretaries at the end of the shift. They rule the department ie Scrubs/Nurse Roberts style. And be nice to the XR and rads folks...Being sweet gets your CTs done sooner and those reads earlier so you're not sitting at the end of shift waiting.

 

[Birdstrike]

but I do find please and thank you's go a long way.

Yes, positive feedback goes a very long way to influence behavior, and likely much further than a slice of pizza. Logic, reason, and being right, matter little when trying to persuade people to work with you as opposed to against you; that totals maybe 5% of what's needed. 95% of what is needed to persuade people is tied into emotion. An average doc who lets those around him know they are valued is going to be much more powerful in that regard, than the very best of clinicians who makes those around him feel they're lesser. And you're right, doing that doesn't have to cost you a thing. Two books I've read recently do a masterful job of explaining how to better persuade people:

How To Win Friends And Influence People, by Dale Carnegie, and
Influence, by Robert Cialdini.

Spending the $25 and a few hours may not only make you better at influencing people in a mutually beneficial way, not only at work but in all aspects of your life, but may also change the way you view the world. Seriously.

I've read both and probably will read them again.

 

[RoyBasch]

Yes, positive feedback goes a very long way to influence behavior, and likely much further than a slice of pizza. Logic, reason, and being right, matter little when trying to persuade people to work with you as opposed to against you; that totals maybe 5% of what's needed. 95% of what is needed to persuade people is tied into emotion. An average doc who lets those around him know they are valued is going to be much more powerful in that regard, than the very best of clinicians who makes those around him feel they're lesser. And you're right, doing that doesn't have to cost you a thing. Two books I've read recently do a masterful job of explaining how to better persuade people:

How To Win Friends And Influence People, by Dale Carnegie, and
Influence, by Robert Cialdini.

Spending the $25 and a few hours may not only make you better at influencing people in a mutually beneficial way, not only at work but in all aspects of your life, but may also change the way you view the world. Seriously.

I've read both and probably will read them again.

Nothing to add, but I think any resident or young attending should pay heed to this post. Mastering the interpersonal game with the ER staff is a skill unto itself separate from your medical/clinical skills but greatly influences your success in this career and ultimately your patient care outcomes.

 

[Groove]

I'm probably a minority in the game of interpersonal influence with ancillary staff at work, but I've found that nothing works better than a healthy respect/fear of authority. Many nurses are great, have a wonderful work ethic and do their job. Many, shall I say most?...are just plain lazy. They are on their phones, gossiping in the hallway, surfing facebook or instagram, shoveling their face, not paying attention to what lab results are back on their patients, and have zero incentive to discharge in a timely manner or turn the room and create more work for themselves. The PC answer to motivating nurses seems to always boil down to "be extra nice to them, make them feel appreciated and they will BLOSSUM". Sorry, but that's just not my experience. If you're too friendly with them and chummy, they'll inevitably take advantage of you. If you are nice to them....they'll call you an ass**** on the single occasion where you need to reprimand them.

My policy over the years has been to always keep a professional level of respect/distance from the nurses. The distance maintained makes them feel less inclined to try to take advantage of me or bank on the fact that I'll let something slide...(after all, we're buddies right?!..wrong). I'm polite, I say hello and ask them how their weekend was, etc.. but I don't get too personal with them and they know absolutely nothing of my personal life outside of work. What they do know is that I have very high expectations for their level of work and that I will only allow so many things to slide before I go to their boss to get things done. I'm professional, I don't yell, but I definitely let them know when I'm unhappy that something didn't get done that should have been done two hours ago. It might not make me the the nurses favorite attending but I'm def one of the most respected and they know I don't take bull****. I compliment them when it's appropriate, and I aim not to create a malignant environment, but we're there to take care of patients...An ER is not a high school experiment. Plus, nursing turnover is so high that I find it horribly low yield to invest too much interpersonal motivation with individual nurses because inevitably they are gone in a few months or a year. Who's got time for that?

It's not the nurses' good side that you need to make sure you're on, but nursing MANAGEMENT. Nursing management are the ones that can make your life miserable in the long run. Aren't you glad you became a DOCTAH?! 😀

 

[Groove]

Free tip for the new attendings... Anytime you do bring something to the attention of nursing management (or hospital management) for that matter. Never frame it in the context of "this really pissed me off and I'm angry....make it change!", etc.. but rather frame it in the context of patient safety. "I'm concerned about the delay in X because it delayed an admission by 2 hours while 20 patients were in the waiting room and I'm concerned about a poor pt outcome and worsening metrics that could be easily avoided by having nurse(s) do Y in a timely manner, etc.."

They really hate that. Especially when you leave a paper trail with "patient safety" concerns sprinkled throughout. It gets things done though. Don't ever make it personal. You'll end up just singling yourself out as a "problem attending" in need of an attitude adjustment or extra professionalism CMEs.