How to deal with EM anxiety

[rogerrabbit221]

I need help. I have been practicing as an attending for about 3 years. I am working reasonable hours. I feel like the more I work, the more I second guess myself. I had a few bad cases and I've been even more stressed and anxious (and ashamed). I've heard people say the uncertainty gets better the more you practice, but for me, things are getting worse. I am cherry-picking lower acuity patients because I am just terrified of making a mistake and doing harm to the sicker patients or not knowing how to manage patients. I did not get held back or had major issues during residency. I am planning my exit from emergency medicine and will ideally be out of the field in the next few months. I have tried medications and therapy, but none of it really helps.

But I need to get through the next few months at my current job. Quitting today or tomorrow is not an option. I need to know how to move on and survive each shift. How do you deal with EM shift dread before and during the shifts? Youtube? Meditation? Any advice would be appreciated.

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[thegenius]

Can you tell your boss the truth and get appropriate accommodations? If a colleague of mine was going to be leaving in the next few months, and there was a general request to have me see the sicker patients and leave some more of the fast track / urgent care stuff to the doc, I would accommodate that.

It sounds like you're making the right move by exiting EM. Sorry you had to go through this. I agree with others who have said it should get easier with time. If EM is not, then EM isnt for you.

Hard to know what to say in the meantime. Order a lot of tests, even if you think they are needless, and spend a lot of time talking to patients. They like that and will be less willing to say something bad about you or to sue.

I remember just recently I had an elderly woman with pretty severe abd pain, and was quite tender. Labs were normal and CT showed constipation and some very small inguinal hernias. I almost considered admitting her because I was nervous I was missing something, (I didn't necessarily think constipation explained her symptoms) but it would have been a tough sell and a fight, and I kind of didn't want to because maybe she wasn't actually sick. I didn't really know what to do.

So I talked to her. I re-examined her, sat in a chair in the room and showed her the pictures, answered all her questions and she was happy about it. She might come back in a few days due to worsening pain, but I was certain that 1) she wasn't critically il, 2) didn't need antibiotics, 3) didn't need emergency surgery, and 4) and 98% certain she didn't have a dangerous medical problem.

You probably know a lot more than you think too, BTW.

 

[kuc4001]

Hi there. Probably an irrelevant inquiry. May I ask what you do to exit EM in a few months? I am also contemplating on leaving EM. Many thanks in advance.

 

[Mount Asclepius]

Never run to an emergency. You aren’t having an emergency.

EM isn’t for everyone. It may not be for anyone.

Rely on your training. Build on that with experience.

Your peak is 5 years out. You are close, but still growing and it still isn’t always smooth sailing.

The field is stressful, but usually not in the ways the lay person thinks.

 

[CoolDoc1729]

Ironically I think working solo midnights cemented my confidence - where before I second guessed myself constantly, there’s no one else to ask when I’m the only attending in the house so I just have to make a decision at some point. If I’m not sure what to do I don’t rush dispo, I let it bounce around in the back of my head for a bit while I’m doing simpler tasks.

As @thegenius said you can always take some extra time with the patient when you are in a quandary. The tests are showing this, I can’t rule out that, do you want to go home or stay/get additional test/see consultant etc.

Also, if there’s any test you consider ordering, (most of our tests are relatively harmless) order whatever you need to feel comfortable that you aren’t missing things. This isn’t the time to try to be a minimalist. Especially if you’re planning an exit anyway, who cares about metrics ? Take your time and order whatever you need to sleep at night.

 

[betamale]

I need help. I have been practicing as an attending for about 3 years. I am working reasonable hours. I feel like the more I work, the more I second guess myself. I had a few bad cases and I've been even more stressed and anxious (and ashamed). I've heard people say the uncertainty gets better the more you practice, but for me, things are getting worse. I am cherry-picking lower acuity patients because I am just terrified of making a mistake and doing harm to the sicker patients or not knowing how to manage patients. I did not get held back or had major issues during residency. I am planning my exit from emergency medicine and will ideally be out of the field in the next few months. I have tried medications and therapy, but none of it really helps.

But I need to get through the next few months at my current job. Quitting today or tomorrow is not an option. I need to know how to move on and survive each shift. How do you deal with EM shift dread before and during the shifts? Youtube? Meditation? Any advice would be appreciated.

Anxiety is the worst. Hopefully things work out. Try lower acuity places like VA or a really low volume surgical center free standing

 

[Arcan57]

I had a few bad cases and I've been even more stressed and anxious (and ashamed).
( )
But I need to get through the next few months at my current job. Quitting today or tomorrow is not an option. I need to know how to move on and survive each shift. How do you deal with EM shift dread before and during the shifts? Youtube? Meditation? Any advice would be appreciated.

So you've had a few bad cases. What made them go badly? In EM, things go sideways for all kinds of reasons. Some of the reasons are going to be specific to the ED doc but a lot aren't.

Looking back, would you doing something different have significantly improved the outcome? If not, take comfort in that and don't beat yourself up.

If you doing something different would have mattered, is it reasonable to expect that you would have done better given the circumstances that existed at the time? The retrospectoscope is a useful tool but tends to get gunked up knowledge of what actually happened.

If it's reasonable to expect you could have done better, what interfered with your performance?

Was it a lack of knowledge/skill? Read or do sim stuff, pledge to do better next time

Did you have the knowledge but couldn't access it in a timely fashion? If so, was the timing really as critical as you perceived it to be? Almost nothing in EM requires split second decisions, most things will wait 30 seconds to a minute especially if you're talking through your process so the team doesn't start freaking out. If it really was that time critical, find an algorithm to follow for when you're tunnel visioned. Intubation checklists, AHA cards, etc.

In all of these scenarios, having a growth mindset is really useful. Keeping the following in mind is also important:

1) We play percentages. Having zero risk tolerance doesn't mean having zero bad outcomes. Non-specific presentations of rare, rapidly fatal diseases happen commonly when viewed at a population level.

2) All of the things that make a great emergency medicine doctor are things that can be trained and improved upon. Great docs still have bad outcomes.

3) Fear is the mindkiller. Panic makes it harder to utilize any of our skills. The amount of distress we can tolerate before panicking is something that can be improved upon (think about what freaked you out as an intern vs. as a 3rd year). Disassociating into an intellectual space can help if you are panicking. Instead of focusing on not knowing what to do, start listing out problems and solutions in your head. The gibbering terror will still be in the back of your mind but if you're not connected to that space then it doesn't mess with you.

 

[Groove]

Hmm, yeah you may not be cut out for EM. I'd recommend urgent care or Telehealth. VA would also be a consideration given the low acuity and sovereign immunity.

You could also try a lost dose beta blocker before each shift. I've done that for years and it kind of keeps me calm and my hands don't shake during procedures and I rarely feel flustered. It kind of knocks out that physiologic feedback loop that leads to anxiety.

 

[rogerrabbit221]

Hi there. Probably an irrelevant inquiry. May I ask what you do to exit EM in a few months? I am also contemplating on leaving EM. Many thanks in advance.

HPM fellowship

 

[Fox800]

Working on a small tropical island can do wonders for your career. Plus the beach and the ocean/diving are meditative.

HPM fellowship, pain fellowship.

Maybe do a stint on a cruise ship or do a remote/Antarctica mission.

The VA might not be bad.

 

[Groove]

Working on a small tropical island can do wonders for your career. Plus the beach and the ocean/diving are meditative.

HPM fellowship, pain fellowship.

Maybe do a stint on a cruise ship or do a remote/Antarctica mission.

The VA might not be bad.

Damn, what kind of gig do you have? We have a Caribbean vaca place that we go to every year and as we pass one of the Caribbean hospitals...I always think to myself..."Maybe one day....".

 

[RuralEDDoc]

I wonder how much pace may be an issue here. Primary care docs vary widely, some have relatively decent clinics but many have very busy clinics that would really surprise many ER docs. I would echo the VA comments above, many sites are slower paced with decent pay and killer benefits.
Also re: acuity - most lawsuits I see don’t come from super high acuity cases. People who come in dying just really don’t sue very often as their survival probability was low to begin with. It’s the semi-healthy with bad outcomes that sue, like a young woman with kids with a bad stroke that’s (reasonably) missed on initial presentation. I would recommend against cherry picking and take what comes your way, you can’t easily guess your way out of liability.

 

[rogerrabbit221]

It's the high acuity cases (or anticipation of) high acuity cases that ramp my anxiety up. I do worry about lawsuits but more so I just worry about taking good care of my patients. EM docs should want to manage the super sick patients, right? I don't... Of course, I have to manage them if I get them, but there's also a big part of me that tends to freeze up and mentally spiral. I can't act as decisively as my colleagues and I'm sure the nurses see that as well.

I guess I'll continue reading. It's hard to keep the emotions and anxiety out of the job, but maybe I'll try some meditation? Thanks for the advices.

 

[Angry Birds]

I had this 3 years out. Now I’m in my 8th year and feel like I can do this job in my sleep.

Are you 100 percent sure it’s not your practice environment? Why not try a lower volume ER before jumping ship? Unless you are totally happy with your new plan of course.

 

[RustedFox]

It's the high acuity cases (or anticipation of) high acuity cases that ramp my anxiety up. I do worry about lawsuits but more so I just worry about taking good care of my patients. EM docs should want to manage the super sick patients, right? I don't... Of course, I have to manage them if I get them, but there's also a big part of me that tends to freeze up and mentally spiral. I can't act as decisively as my colleagues and I'm sure the nurses see that as well.

I guess I'll continue reading. It's hard to keep the emotions and anxiety out of the job, but maybe I'll try some meditation? Thanks for the advices.

I'mma be real with you, chief.

Get out. The sooner the better.
This whole field is going to be far worse, really fast.
I'm not saying you can't handle it, or that you're psychologically weak, or whatever.
I'm telling you: this boat is on fire and it's starting to sink.

I've been thru the worst of EM.
Jackpot lawsuit? - Check.
New contract every 8 months with the choice of "sign or leave"? - Check.
Being the only full-time doc left at a site where ALL others left and having my hours increase 50% without my consent? - Check.
Completely unfounded patient complaint leading to all sorts of review ? - Check.
Burning the eff out and becoming a terrific alcoholic mess that took a year off of working in EM? - Check.

It's not worth it. The sooner you embrace a new career and identity, the better.

 

[HemorrhagicShock]

Burning the eff out and becoming a terrific alcoholic mess that took a year off of working in EM? - Check.

How was coming back after an entire year off?

(I am assuming you came back)

Did you not do anything clinical that year?

 

[ERMudPhud]

I wish there was an answer to this question. I really do. EM anxiety took the careers and in one case the life of people I care about. After watching lots of EM docs for the last 25 years I think some of us are just more sociopathic than others. The sociopaths survive. I tell residents "Every patient you see today is going to die. Some sooner than others. Some a bit later because of you. Hopefully none a bit early because of you but they are all going to die eventually." Its sort of joke but it sort of isn't.

In the last 25 years I can count on one hand the number of patients that caused me to loose sleep the next night. Not because I'm great or never make mistakes but because the mistakes don't stick to me like they do to some of my friends. Like I said the sociopaths survive. I learn from the bad cases. I try to do better but I don't spend the next 5 days after I see them worrying about them, reading about them, obsessively studying about them. I'm not better at this then other docs. None of us are. There might be someone claiming to be the number one pediatric neurosurgeon in the world but there is no best EM doc in the world. We all are just doing the best we can and no matter how much we worry we aren't good enough the patient is better off having us there than not. If they wanted the best EM doctor in the world they should have planned their emergency better. So, now they have to settle for me (or you), the good enough EM docs.

You might be being a bit hard on yourself. You are only 3 years out. You aren't at the height of your superpowers until 5-10 after you finish residency. It's all down hill after that. I know. I'm coasting into the finish line. Even after 20 years there are things you will have never done even if your friends have done a bunch. After 25 years I still haven't done a lateral canthotomy although I thought I was going to finally get one 2 nights ago. I only did my first jaw dislocation after 20 years. I've done other things my friends have only read about. Sometimes our personal case mix is just random.

But you don't have to worry and read about every presentation and every procedure. No one can memorize all that. If they are dead or mostly dead(Princess Bride reference) than just do your usual resusc stuff. It's not that complicated. Anything else and you can take 5 minutes to read. Go refresh your memory with Up-to-Date or quick procedure video or google or whatever you need. No one will think less of you for it. **** I once diagnosed someone with Churg-Strauss because I took the time to type mono-neuropathy, pneumonia and asthma into Dr. Google. I had this vague memory they all hung together somehow but I certainly hadn't memorized that presentation.

So, know that you are better at this than you think. Know that you will continue to get better at this for at least another 5 years. But also if you know yourself well enough to know its not right then get out now. And get real help if you need it. We all tried to make excuses and find work arounds for my friend who killed himself. We should have just put him on a mental health hold. Don't let it get to that point. Find help and just quit early if you need to.

 

[ERMudPhud]

I had a few bad cases and I've been even more stressed and anxious (and ashamed). I

Oh yeah, its hard but try not to be ashamed. We don't do shameful things. We do the best we can under difficult circumstances and sometimes we are right and sometimes we learn from our mistakes but we don't do anything worthy of shame. This isn't performance art and there is no olympic medal for EM. So, there is no shame in not being perfect.

 

[RustedFox]

How was coming back after an entire year off?

(I am assuming you came back)

Did you not do anything clinical that year?

At first, I felt like I "lost a step", but looking back - I didn't. I felt appropriately unsure of myself, but in no way was I "incompetent". All the reflexes were still there.

I did non-clinical stuff while the radioactivity that is EM left my body. I'm getting close to making a huge career pivot. I'm already down to 4-5 EM shifts/month and plan to go down further. I want to keep my ABEM certification active in case I'm wrong and EM gets better, but that's wishful thinking.

 

[TrailRun]

This is such a scary job. At any point someone can bring you a dying (or dead) baby, etc etc, and you’re supposed to manage, often with no support or resources. Add to that the fact that we are trained by necessity to think of worst first. Child with a headache - brain tumor? Non-accidental trauma? New incontinence - being molested or just a uti. Back pain - leukemia or just a muscle strain, etc. and it’s easy for that to spill over into your personal life. Add to that the stress of the pace and trying to manage patient and admin unreasonable expectations it’s all overwhelming. I personally think EVERYONE in EM (but perhaps in every job really) should have an actionable plan B. Like urgent care, still have volume pressure and patient expectations but not life and death.

Meditating before shifts has been helpful for me. Good luck!

 

[WhatJobDoIPick]

The posters above did such a good job that I won't expound on a lot.

OP, we've all been there at one point.

I heavily advise a practice environment change. I just escaped a toxic pit that I thought would be my forever job

Lurking medical students: PLEASE take heed. We don't say this stuff cause we're old wrinkly grumpy people. We say it out of legit concerns for you, you random Internet person. My former residents are all looking for ways out. There's a reason for this.

 

[RustedFox]

The posters above did such a good job that I won't expound on a lot.

OP, we've all been there at one point.

I heavily advise a practice environment change. I just escaped a toxic pit that I thought would be my forever job

Lurking medical students: PLEASE take heed. We don't say this stuff cause we're old wrinkly grumpy people. We say it out of legit concerns for you, you random Internet person. My former residents are all looking for ways out. There's a reason for this.

That's the thing: that perfect job won't stay perfect. It has a high likelihood of turning to a reactor fire at any time.

 

[Fox800]

I'mma be real with you, chief.

Get out. The sooner the better.
This whole field is going to be far worse, really fast.
I'm not saying you can't handle it, or that you're psychologically weak, or whatever.
I'm telling you: this boat is on fire and it's starting to sink.

I've been thru the worst of EM.
Jackpot lawsuit? - Check.
New contract every 8 months with the choice of "sign or leave"? - Check.
Being the only full-time doc left at a site where ALL others left and having my hours increase 50% without my consent? - Check.
Completely unfounded patient complaint leading to all sorts of review ? - Check.
Burning the eff out and becoming a terrific alcoholic mess that took a year off of working in EM? - Check.

It's not worth it. The sooner you embrace a new career and identity, the better.

Yep.

Volumes: through the roof.
Pay: stagnant for TWENTY YEARS. How?
House prices: soaring.
Reimbursements: government tryna cut. Our healthcare heroes sincerely thank you for that slap in the face.
Staffing: always in crisis.
Nurses: more junior.
Inpatient beds: none.
Patients: meaner, more entitled.
Healthcare heroes: LOL get out of here with that. That's so 2020.
Pizza: cold.

 

[Fox800]

Damn, what kind of gig do you have? We have a Caribbean vaca place that we go to every year and as we pass one of the Caribbean hospitals...I always think to myself..."Maybe one day....".

Not hard to find, they're always all over Global Medical ads. USVI, Guam, Saipan. All are US territories. Go get a tan...

 

[CoolDoc1729]

Yep.

Volumes: through the roof.
Pay: stagnant for TWENTY YEARS. How?
House prices: soaring.
Reimbursements: government tryna cut. Our healthcare heroes sincerely thank you for that slap in the face.
Staffing: always in crisis.
Nurses: more junior.
Inpatient beds: none.
Patients: meaner, more entitled.
Healthcare heroes: LOL get out of here with that. That's so 2020.
Pizza: cold.

Healthcare heroes literally lasted a month and now everyone is rude and super impatient.

Do you work at my hospital ? 🤣

 

[betamale]

Not hard to find, they're always all over Global Medical ads. USVI, Guam, Saipan. All are US territories. Go get a tan...

one of my colleagues who worked in St. Croix told me all the really sick patients/trauma or require XYZ advanced procedure/specialist will need transfer by fixed wing. i don't think that's gonna go well if you already have crippling anxiety

 

[ScepticSkeksis]

I echo what Rusty said above. I'm going to be out of EM entirely this year. The best thing to do is get a side gig you can do from your home. If you have even a bit of extra income it can get rid of the anxiety and "what if I get fired?" thoughts that can destroy your mental well-being. Extra income can be telemed, real estate rentals, or even simple income-generating Stocks/ETFS. Once you have $5-10K of non EM income you have the freedom to explore whatever you want to do. If your timeline is a few months, then start now and keep building your side income. There are a few dividend stocks that have paid out 8-10% per year for 25 years.

 

[rogerrabbit221]

I had this 3 years out. Now I’m in my 8th year and feel like I can do this job in my sleep.

Are you 100 percent sure it’s not your practice environment? Why not try a lower volume ER before jumping ship? Unless you are totally happy with your new plan of course.

I've tried the lower acuity gig. My prior jobs have me alternating between a higher acuity + a lower volume/acuity place. Still sucks and deal with same amount of anxiety cause the lower volume place means fewer resources and transferring to other hospitals is a nightmare when there's no beds.

 

[EmergentMagician]

Finishing up Palliative fellowship this year- worked in the trenches for several years before that. Can relate to these waxing/waning cycles of anxiety and self doubt.

What worked for me in the short term: minimizing caffeine on shift, see less patients, go back to the basics of reviewing ACLS/ATLS/PALS, and take some time off.

I took around 7 months off from the ED during fellowship, then started picking up shifts again at a low acuity site. I never would have thought possible- but I was actually missing the ED.

Night and day difference in my approach to patient care in the ED, and overall stress level.

Granted, I have officially sworn off working anywhere >1.5 pph, <200$/hr, and refuse to work nights. Easy admits, low transfer burden is a must. I don't know how sustainable that will be, but this is my new line in the sand.

Fellowship will give you the perspective on how much (if any) of the ED you will be willing to tolerate moving forward.

Having been a part of the inpatient and outpatient care delivery model for the past year has really opened my eyes to a lot of things.

For example, I used to get VERY worked about about appropriateness of ER visits/referrals, and medicolegal concerns. To the point of actively ruminating throughout my days on/off shift, and drinking (etoh) a lot.

This has all disappeared- I tend to focus a lot more now on relationships rather than pph and appropriateness of care (physician-physician relationships, physician-patient, physician-nurse, and *gasp* even physician-admin)

As promised, I will eventually post a comprehensive take on my evolution through palliative.

Feel free to message if you want to discuss further

 

[HemorrhagicShock]

Granted, I have officially sworn off working anywhere >1.5 pph, <200$/hr, and refuse to work nights. Easy admits, low transfer burden is a must. I don't know how sustainable that will be, but this is my new line in the sand.

How did you go about finding these places?

These kinds of numbers seem like a fantasy in this market.

Recruiters and directors will often lie too. An advertised 1.8 per hour sometimes ends up being a 2.2 per hour.

Especially in or near any desirable place to live (and/or near places where one's spouse can work if they're in an industry that isn't medicine)

 

[EmergentMagician]

How did you go about finding these places?

These kinds of numbers seem like a fantasy in this market.

Recruiters and directors will often lie too. An advertised 1.8 per hour sometimes ends up being a 2.2 per hour.

Especially in or near any desirable place to live (and/or near places where one's spouse can work if they're in an industry that isn't medicine)

Agree- this is an unusual job, and likely not sustainable. It was part of the reason why I came out of EM retirement (only doing 2 weekends/month right now). I'm moving to a rural area next year and will be looking for those critical access, low volume jobs.

In retrospect, seeing >2.5 pph was what burned me out the worst. It set the stage for all of the factors to take hold (circadian stuff, medicolegal stuff, pt expectations, etc. etc.)