Holy crap- I'm an attending now

[kat82]

And I'm a little nervous for my first shift next week. Up until recently I felt pretty confident about my abilities as an ER physician, but now I find myself frantic and feeling like I know NOTHING (and I know there is still plenty to learn)! Is this normal? I am sure I'll be second guessing everything I do. It's a lot easier to feel confident in your plans when you have an attending supervising you.

Any advice for us newbies? Is this pre-attending panic normal?

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[pinipig523]

And I'm a little nervous for my first shift next week. Up until recently I felt pretty confident about my abilities as an ER physician, but now I find myself frantic and feeling like I know NOTHING (and I know there is still plenty to learn)! Is this normal? I am sure I'll be second guessing everything I do. It's a lot easier to feel confident in your plans when you have an attending supervising you.

Any advice for us newbies? Is this pre-attending panic normal?

Same position I'm in.

If you're not somewhat anxious or a little scared - then you should be worried. Those who think they know enough know nothing at all. It's those of us who are scared because we know the limits of our knowledge who are truly ready for attending-ship.

 

[Apollyon]

Somewhere around the middle of residency, it should have gone from "Is it?" to "It is." Still, you'll have questions. The medicine is the same - remember that.

If you have questions, ask your colleagues. However, as stated in another thread, don't ask "What would you do?". Say, "This is what I would do, but does that work around here?", or "I'm thinking 'x' - what do you think?". Act like a peer - not like you are still a resident.

 

[WilcoWorld]

I damn-near puked twice on the way to my first attending shift. The way you're feeling is normal.

It'll be tough, but if you graduated from an accredited residency then you're in good shape. Just think of how many non-BC/BE docs are treating any and all fevers with levaquin, sepsis with peripheral dopamine, and aortic dissections with nitro - you may have some growing to do (which is mostly confidence-based and not knowledge-based), but you're likely already practicing at or above the standard of care...whatever that means.

 

[RustedFox]

I was walking down one of the aisles at the supermarket earlier when I had one of these above-described moments of "panic". By the time I made it down the aisle, I said to myself - "Wait a minute... it can't be much different from what I do already. When I think back... in my "senior year", before I even spoke to an attending about my patients, I had 3-4-5 of them cocked, chambered, and ready to fire.

You know what you're going to do with a complaint, an eval, a chart, a... whatever. So, go do it.

*Disclaimer: yeah, I'm sometimes as afraid as you are, brother pig. Good luck to yah.*

 

[kat82]

I also fear I'll be TOO conservative because I'll be so anxious about missing that MI, etc (more so than I would have been as a resident) Especially after reading about that awful lawsuit at Temple. I don't want to be criticized for doing overly extensive workups. I don't want to look like a weakling.

My panicked moments occur at night, as I'm trying to fall asleep. I'm so tired

 

[WilcoWorld]

I also fear I'll be TOO conservative because I'll be so anxious about missing that MI, etc ...

You probably will be a little overly conservative at first. I was. But I think most partners are more willing to forgive the new guy (or gal) for being conservative than for being cavalier.

That's to say that yes, you might want to streamline your work-ups after a couple of months, but that's the right side of the spectrum for a new grad to be coming from.

 

[kat82]

Thanks all. Any other general tips would be useful for me as well as other newbies as I think most of us will be starting in a couple of days

 

[la gringa]

in my now 3 years out, my toughest moments had nothing to do with the MEDICINE... they were about people -- erratic flow, difficult nurses/consultants/families (occasionally, but rarely, actually THE PATIENT), balancing patient satisfaction vs speed...

 

[Zanegray]

Last resident shift today.

But I have been moonlighting in my new shop so I have had some of those jitters/issues so far. But its improving. Still scared but better -

One of my attendings taught us the following - when unsure -

LICA - labs image consult admit. works pretty well, I sleep easier this way.
He also loves to say "a picture is worth a thousand words, and a CT scan is a thousand pictures" - so so what if I over test for awhile. Its a hell of a lot better than worrying.

Good luck to you all. Its nice to know we're in the same boat!

 

[Arcan57]

Last resident shift today.

But I have been moonlighting in my new shop so I have had some of those jitters/issues so far. But its improving. Still scared but better -

One of my attendings taught us the following - when unsure -

LICA - labs image consult admit. works pretty well, I sleep easier this way.
He also loves to say "a picture is worth a thousand words, and a CT scan is a thousand pictures" - so so what if I over test for awhile. Its a hell of a lot better than worrying.

As long as you start tapering your CT ordering back to your group's baseline quickly, this isn't a horrible strategy. If you lean on it too much then it becomes your practice style, and you become "that doc". The doc that the nurses hate because every work-up includes cross-sectional imaging and your partners can tell that you're on shift by looking at the waiting room. If you think the patient is sick and don't know what's going on, scan away. But if you don't think the patient is sick and you don't know what's going on, learn to get comfortable with conveying that to the patient and leave the CT scanner dormant.

 

[The White Coat Investor]

Remember that in general older doctors are more conservative than younger doctors (politically and in their practice.) There's a reason for that.

You know why that 55 year old guy ordered that CT on that patient with the odd presentation when you wouldn't have? Cause he's been burned before when he didn't.

 

[Pinner Doc]

The biggest surprise to me was how much community practices put stock in stupid crap, like door to doc times (our goal - under 15 min), door to dispo times, average scans ordered, percent transfers, percent admits. I, too, started out as a leaning on the conservative side, and I heard about it from the nurses and from my director. I don't know if there's any way around that. As others have said, you really should err on the more conservative, rather than cavalier, side when you are starting out. Do what's best for the patient. You'll pick up the nuances of the group and the flow with time.

 

[alreadylernd]

in my now 3 years out, my toughest moments had nothing to do with the MEDICINE... they were about people -- erratic flow, difficult nurses/consultants/families (occasionally, but rarely, actually THE PATIENT), balancing patient satisfaction vs speed...

Attending a few years out of residency here, I definitely agree with the above post. Things to keep in mind when transitioning from residency to "being on your own."

1. Have an idea of what your group is "grading" you on. No one cares about your inservice scores, it's pts/hr and/or rvus/hr, it's press ganey or equivalent, bounce backs, "quality" measures, door-to-dispo. Ask someone in your group (or maybe it's spelled out in bonus/contract)

2. All the frequent patients will be new to you, but don't let nurses/staff talk you out of doing what you feel is right for one of the "frequent flyers" that everyone else knows. Staff will try and talk you out of everything - tests, gowning a patient, complete vital signs etc. It's a work issue on their part, they want to see what they can get away with with you. These same staff members who are telling you "nothing is wrong" with that frequent drunk, or psych patient, will simultaneously document in the triage note all the "complaints" the patient listed (legitimate or otherwise)

3. Learn which nurses/techs you can trust, and which ones...well, you know. Be professional to everyone, but make sure to particularly thank those who are working harder than others to help you and the rest of the department. Learning first names is key and appreciated.

4. Try and learn first names of consultants. Just as in residency it was easier to call your friends on other services for admissions/consults, the same is true in the community.

 

[EM_Rebuilder]

Start early on becoming active outside of just seeing patients. Get on hospital committees, work with ACEP/SAEM/AAEM and your state EM chapters and medical association.. the county medical society is important also and a place to meet other community docs.

The group I joined had near zero interest in the local/state/national organizations. That was a niche I have quickly filled in my less than year of being here. Much of the private world does not want to be involved, but nearly all recognize the importance of someone being involved.

My group supports me with the time off to travel for state/national organzitions.. Its fun meeting people, often big names in EM or in your state... And if you ever want to leave your job.. well I've had multiple job offers and could easily leave if I ever have the desire... Networking is fun, important, and I think peers at home have a different level of respect when they know you are out doing that stuff.

I agree with what someone else said above about figuring out what it is your group or you hospital/admin cares most about. Hospitals care about different things; my hospital placed patient satisfaction as the most important.. they would rather us slow down, make multiple trips to patient rooms to explain, sit on stools, print out handouts, etc etc... they rather you do that than see 3pph. Other places its all about patients per hour... other places are more of a balance.

 

[Khaos]

As long as you start tapering your CT ordering back to your group's baseline quickly, this isn't a horrible strategy. If you lean on it too much then it becomes your practice style, and you become "that doc". The doc that the nurses hate because every work-up includes cross-sectional imaging and your partners can tell that you're on shift by looking at the waiting room. If you think the patient is sick and don't know what's going on, scan away. But if you don't think the patient is sick and you don't know what's going on, learn to get comfortable with conveying that to the patient and leave the CT scanner dormant.

I agree with this one. The average at our place is around 20%. One of the docs has a 43% scan rate. Everyone knows when he's on, everyone knows the waiting room is going to be full. There is one plus, the nurses are extra thankful when they see you coming in to relieve him.

Being scared of your first shift is normal. I did a lot of moonlighting my third year and learned several things. The interns that asked about moonlighting always asked about the traumas, sick patients, and coding patients. Those are the easy ones. You know the protocol for those. Intubate, put a line in, and transfer (if working in a small place) or call the intesivist/cardiologist/surgeon if not. The ones that you seem to second guess are the old people. The 80 yo little old lady that has never been to the emergency department and has this non-specific abdominal complaint. That is a good time not to be stingy. Use everything you got...and when everything comes back normal, call their regular doc, discuss everything with them, and go with your gut. If they look sick despite everything discuss admission. If they are walking around,nice as can be, and look great discuss close follow up. Use the primary care docs and consults up..they get paid to be on call and can spread some of the liability.

 

[CraftyMed]

2. All the frequent patients will be new to you, but don't let nurses/staff talk you out of doing what you feel is right for one of the "frequent flyers" that everyone else knows. Staff will try and talk you out of everything - tests, gowning a patient, complete vital signs etc. It's a work issue on their part, they want to see what they can get away with with you. These same staff members who are telling you "nothing is wrong" with that frequent drunk, or psych patient, will simultaneously document in the triage note all the "complaints" the patient listed (legitimate or otherwise)

3. Learn which nurses/techs you can trust, and which ones...well, you know. Be professional to everyone, but make sure to particularly thank those who are working harder than others to help you and the rest of the department. Learning first names is key and appreciated.

Granted, I love my nursing/tech staff. I couldn't get my job done without their help and I respect that. BUT, don't let them paint the entire picture for you. I have a nurse who always downgrades and blows off people's complaints. Many times there's a lot more to the story, but she doesn't want to hear it. Yup, that Level 5/Blue "earache" patient had a Hemoglobin of 3.6. (and yes, it's been addressed with nursing admin, but what can you do? )

 

[tkim]

Granted, I love my nursing/tech staff. I couldn't get my job done without their help and I respect that. BUT, don't let them paint the entire picture for you. I have a nurse who always downgrades and blows off people's complaints. Many times there's a lot more to the story, but she doesn't want to hear it. Yup, that Level 5/Blue "earache" patient had a Hemoglobin of 3.6. (and yes, it's been addressed with nursing admin, but what can you do? )

+1

Got a veteran RN in my shop who will minimize the complaint to 'speed' dispo. 2X y/o F c/o dizziness, feeling better after 1L bolus. Noted increased thirst x 3 days, h/o PCOS. Questioned my orders for labs. "She's fine now - why lab her up?" Turns out new onset DM in DKA. Unit admit on insulin gtt.

 

[la gringa]

it takes some time, but until you figure out what nurses to trust, DO NOT let them talk you out of things. might seem like a good strategy short-term, but you'll learn with time that a few really are trying to minimize work. they aren't getting a pt satisfaction survey with THEIR NAME on it, and if something bad happens, they aren't the one majorly on the hook.

i've caught new onset leukemia, ARF, anemia in pts that a nurse tried to blow off for their c/o weak/dizzy/flu like sx.

 

[8654Marine]

2 way street:

Nurses know which doc orders appropriate tests and which don't.

I know which nurses are prone to inappropriate triages: rushing an 18 y.o. w/ "CP" with normal VS to the trauma room while letting the 60 y.o. fall off horse on head, on coumadin lounge in the waiting room.

You should hear the lament when certain attendings are on: rectal temps for everyone and orthostatics on everyone. This person orders X-ray then CT of C-spine. Or US of pelvis then CT of Abd. Or orders D-dimer and trop on "CP".

 

[RustedFox]

2 way street:

Nurses know which doc orders appropriate tests and which don't.
You should hear the lament when certain attendings are on: rectal temps for everyone and orthostatics on everyone. This person orders X-ray then CT of C-spine. Or US of pelvis then CT of Abd. Or orders D-dimer and trop on "CP".

Ahhhhh.... we had a duo of docs at my old place who would do things like that all the time and frustrate the residents to no end. 13 year-old female with left adnexal pain and wonky periods, hasn't tried anything for pain. Triaged as "purple - lowest acuity" I get a negative pregnancy test and urinalysis, gave her a hit of naprosyn, which completely resolved her pain. She's ready to go, mom is thankful for getting her seen and "fixed" so quickly. Attending says - "She'll be in to see her in just a few minutes." Several hours later, I "happen to notice" that the doc finally got around to seeing the little one.... and has now ordered CBC, BMP, belly labs, lactate, pelvic exam, urine drug screen... all after I had set the expectation with patient's mother that they'd "be able to leave very soon".

 

[kat82]

Update: I've survived 2 shifts so far and am grateful for all of your comments!