New attending woes

[EskimoFriend13]

Hi guys,


New attending here looking for advice and encouragement on a couple of things:

1. I am so so nervous both before shift, during, and after (when I replay everything in my head). I know this is normal to some degree, but my current stress level is not sustainable and I'm wondering how long until I get some relief. And I haven't even started single coverage shifts yet which I'm really dreading.
2. I think the above is largely due to my fear of making a critical error or discharging someone home who then dies. Even doing my best, that could still happen. How do you guys make peace with that possibility always lurking?

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[res1cue]

Wow Im glad its not just me. Fresh out of residency and I seriously underestimated the mental load associated with being the sole person making all the decisions

My days off, I just think about the people I discharged wondering if I should have done something different

 

[GeneralVeers]

You will make mistakes. People will die regardless of how good your care is. Discharged people may have a bad outcome and return.

It never changes, but you do have to just learn to not worry about it, otherwise you can't be functional. With experience you will build up confidence and the fears will diminish.

 

[killdevil]

Hey -- I'm one year out of residency and this is EXACTLY how I felt after shifts for the first 4 months or so. Replaying everything in my head, trying to ensure I'd done the right thing, stressing out for hours or days afterwards.

Things got much better a few months out. There are certainly cases I replay and stress over, and which I follow through their hospitalization to make sure my thought process was the right one, but it's much more infrequent than it was at first.

People come to you because they think they are having emergencies. In some small minority of cases, they're right, and in an even smaller minority of cases there's not much you'll be able to do to halt their decline. People will die in your care. They will die after they leave your care whether brought in or sent out. Dealing with this gets easier with time. Documenting your very rational MDM well and making sure to discuss (and document) your strict return precautions and close followup instructions will help you rest more easily after your shifts.

 

[migm]

trust your training, listen to your gut, take your time, make the safe play every time (get the test, admit don't discharge if you're unsure, re-examine that belly, call them to follow up). the stress is normal and gets better. It never goes away but it does get way way better with time.

 

[Birdstrike]

Hi guys,


New attending here looking for advice and encouragement on a couple of things:

1. I am so so nervous both before shift, during, and after (when I replay everything in my head). I know this is normal to some degree, but my current stress level is not sustainable and I'm wondering how long until I get some relief. And I haven't even started single coverage shifts yet which I'm really dreading.
2. I think the above is largely due to my fear of making a critical error or discharging someone home who then dies. Even doing my best, that could still happen. How do you guys make peace with that possibility always lurking?

1. It fades with time. For me, it was a gradual improvement in this over the first 6 months, improving a little each day. The only way to make it better is to keep working, keep facing the fear and eventually the pressure deflates to a tolerable level. It may be quicker for you.

2. First, you may discharge someone home and they could die, but in a way that had nothing to do with anything you did wrong and for reasons you may not have been able to change. As far as making mistakes, we all do. It's unavoidable. You just do the best you can do and make the decision to be at peace with that, regardless of what happens after that. If you're lucky, most of your errors will be minor, still fall within acceptable 'standard of care' and not affect patient outcome in a meaningful way. That covers you 99.9% of the time. For that other 0.1% possibility, that's what you pay good money for malpractice insurance for. Let them worry about that 0.1%. After all, that's what you're paying them for. Also, always remember the rule from House of God: It's the patient that has the disease, not you. In other words, you cannot experience every patient tragedy, as your own. Certain things are going to happen, because they're 'meant to be.' You can try to alter the course of those patients on a collision course with a bad fate. Sometimes you can deflect their trajectory into the "good outcome" basket. Other times, you try and despite the best of care, they still land in the bad outcome basket. You can only guarantee that you'll try to assure everyone a good outcome. But you cannot guarantee everyone they'll have a good outcome. Be at peace with that, starting right now.

Things will get better. I'm sure of it.

 

[gro2001]

Hi guys,


New attending here looking for advice and encouragement on a couple of things:

1. I am so so nervous both before shift, during, and after (when I replay everything in my head). I know this is normal to some degree, but my current stress level is not sustainable and I'm wondering how long until I get some relief. And I haven't even started single coverage shifts yet which I'm really dreading.
2. I think the above is largely due to my fear of making a critical error or discharging someone home who then dies. Even doing my best, that could still happen. How do you guys make peace with that possibility always lurking?

What you are experiencing is totally normal, common, and probably a good sign. Having said that, it doesn't help you right now. So do these things:

1) Think back to intern year. Remember how scared you were entering orders at first? I was personally terrified for the longest time that I would kill someone with a random tylenol order. I think for me it was a solid month, then things were a little easier. How long did it take that to go away in your case? That's probably how long it will take this time too. Maybe a little less, since it's your second time around.

2) Luxuriate in the orders for a while. For the first month, if you want to do a test or order a medication or admit someone or consult someone: just do it. Don't worry if it makes you weak, or if it's against EBM. Yes, that CT is probably not necessary and antibiotics aren't going to do anything for that cough. Both will make you a little bit more comfortable with your decision though, and you know there are plenty of docs out there who just do all the things all the time anyway. Don't do this forever, but just for the first month.

3) Call your patients. Take down the phone number of all the patients you discharge and call them. It will take you like 2-3 minutes per patient, so you can get through it in an hour before your next shift. Will make you feel so much better.

4) Buy yourself something nice with that first attending paycheck. In general, it's not a good idea to blow your money on silly things and have lifestyle creep, but just that first time buy something you want rather than something you need. Self care and all.

 

[thegenius]

Hi guys,


New attending here looking for advice and encouragement on a couple of things:

1. I am so so nervous both before shift, during, and after (when I replay everything in my head). I know this is normal to some degree, but my current stress level is not sustainable and I'm wondering how long until I get some relief. And I haven't even started single coverage shifts yet which I'm really dreading.
2. I think the above is largely due to my fear of making a critical error or discharging someone home who then dies. Even doing my best, that could still happen. How do you guys make peace with that possibility always lurking?

I agree this is a good sign. I was nervous, and still get nervous on solo-coverage shifts. Thankfully real, true, life-death emergencies (like if you don't do something in 10 minutes they will die) very rarely occur.

There really isn't a problem for a short period of time (months to maybe a year or two) of OVER testing and being conservative. I'm four years out and I'm slowly changing my practice pattern.

For example, it is common to see a young or middle-aged, healthy man or woman come in with abdominal pain. Let's say they have normal vitals, and a reassuring physical exam. And let's say their labs are normal. For the first 12-18 months, I used to CT about 1/2 these people even if they had a whiff of abdominal tenderness. Sometimes I would push really hard just to elicit some tenderness to justify the CT. And I realized that just about 100% of these patients that I just described would have negative CT's (normal vitals, reassuring PE, and normal labs).

So I reduced my CT rate, and it has dropped significantly and it's more like 1/10. And even then that 1/10 almost all of them have no pathology.

The lesson from this is that you should be testing more, it's OK to test more, and PATIENTS LOVE TESTS!!!! I don't think a patient has ever told me "Thank you for doing that test, but I never wanted it even though it proved I don't have a serious problem." They love tests, they think doctors exist to order tests and give antibiotics, so you do that - initially.

As you get comfortable with pathology, risk stratification, and coming up with pre-test probabilities for pathology then you will hone your practice style.

At the end of the day if your thinking about whether you should get that MRI, or admit a young person with a HR of 110 that hasn't changed in 4 hours despite doing a ****load of tests on them, admit them or have the hospitalist consult.

 

[scummie]

Good thread so far. Thinking about an alcoholic I discharged a few days ago instead of enjoying being at home and drinking my own wine! My classmates that I graduated with have kept our group text and it's been helpful to talk to each other about what's been going on. If I am trying to talk myself out of ordering something or admitting somebody, I ignore it and just do it. It's better to sleep at night instead of worrying. My CT rate is probably ridiculously higher compared to the other new grad in my group but I think some of that just depends on your ability to deal with risk. 20s female abdominal pain/discharge? I will labs and UA that all day long. My colleague? No labs, just does UA and preg--calls it a 15 minute dispo. So yeah, I'm slower that that guy and my LOS are longer but I can live with myself. Had another classmate say that they do not get post-reduction films for shoulders. They're like, "What's the point of showing me a Hill-Sachs deformity? If they're moving it and saying their pain is better?" IDK, there's a gray area between standard of care and what people actually do I guess.

 

[EMDOC17]

I was there with you almost a year ago. When I was doing nights (solo covered after 1 am) I felt violently ill. It is to be expected. I’m over a year out now and it’s gotten much better. I still get some nervousness driving in for my solo covered night shifts. I have come to realize that this is good.

You are an attending in the ED. Anything can and will walk through those doors or the EMS bay. Just realize anyone would be nervous in certain situations. You are the best to handle it. If you are not scared ****less as a new attending then you are doing it wrong.

 

[hoot504]

If you are not scared ****less as a new attending then you are doing it wrong.

I'm a month in. I've had several severely sphincter tightening moments. I've activated the cath lab several times, had a half dozen intubations, even relearned how to use the Stryker needle.

I am definitely nervous before, during, and for some time after shift.

But am I "scared ****less"? No.

I'm self-aware enough that I actually give myself anxiety, expecting that I should be more angst-ridden. But I'm really not. I am not even remotely under the impression that I'm a badass, or know everything, or can diagnose the needle in a haystack every time, but I know how to provide good, reasonable care to pretty much everyone that walks through the door. That's what residency prepared me to do.

Is there anyone who had fun during their first month of attendinghood? Because so far, it's a blast.

 

[EMDOC17]

So you are nervous but not scared ****less. Thats great. What I’m getting at is when you are first out of residency it is completely normal and expected to have a significant amount of stress.

I couldn’t keep doing this job with the amount of stress when I showed for my first shift. I really couldn’t keep doing this job with the amount of stress in my first single covered night shift.

The cocky new attending is just as bad as the cocky intern. I see new things everyday. I rely on my senior partners or consultants to help me with those things.

I would argue the new cocky attending is much worse than the cocky intern. At least the intern has someone looking over them...

 

[hoot504]

So you are nervous but not scared ****less. Thats great. What I’m getting at is when you are first out of residency it is completely normal and expected to have a significant amount of stress.

I couldn’t keep doing this job with the amount of stress when I showed for my first shift. I really couldn’t keep doing this job with the amount of stress in my first single covered night shift.

The cocky new attending is just as bad as the cocky intern. I see new things everyday. I rely on my senior partners or consultants to help me with those things.

I would argue the new cocky attending is much worse than the cocky intern. At least the intern has someone looking over them...

Right, but you just reinforced the attitude of "if you aren't ****ting your pants, you're cocky". Seems a bit extreme to me.

Maybe this is just a semantic difference. Maybe my "moderate amount of nervousness" is what other people call ****ting their pants, and what other people call "a significant amount of stress".

 

[normtheniner]

The first month has been challenging for sure. I have a persistent uneasy feeling that seems to peak everytime I sign a discharge order. It is getting less scary as time goes by and I slowly realize that my program did a great job at training and preparing us.

 

[EskimoFriend13]

I'm definitely at the "scared $!?&less" level currently, so it's very helpful to hear that I'm not alone and that people who were also feeling that way at first got through it.

 

[Groove]

I think most new attendings feel this way especially if they didn't do much moonlighting during residency. We did a lot of moonlighting so I don't remember feeling too nervous when staring my first job. Regardless, the good news is that it seems that most people acclimate very quickly. I'd be really surprised if you guys are still very nervous after a 2-3 months. If you weren't ready to take care of pt's on your own, you wouldn't have graduated EM residency. Have faith in that. You've got all the skills needed to be a great emergency physician. If you have double or triple coverage with some seasoned docs, don't hesitate to run things by them if you need a second opinion. It's ok to question yourself at first and that's a good thing. The overconfident new attendings who feel that they are experts on everything are the ones that make me the most nervous and always remind me of the Dunning-Kruger effect curve. The first 1-2 years out is an incredible time of growth and learning.

 

[EskimoFriend13]

Thanks everyone. Im now 6 weeks in. Despite getting good feedback, I am still struggling and have lost weight I didn't have to spare. I think I need to change my cognitive/ emotional approach to get some relief. I would appreciate some feedback.

1. I think I'm expecting too much of myself. In my mind, I'm solely responsible for the health and wellbeing of all my patients and can't miss any possible disease or have any bouncebacks or make any mistakes in general. I realize that is patently unhealthy, but I hang on to it because of a belief that this is what makes me thorough enough to be a good doctor. I guess I'm looking for a more realistic self-standard because the cognitive burden of my current expectations is making me indecisive and possibly could lead to errors.
2. Weird/ vague combinations of complaints. I'm getting way more of these than I did in residency. Things where there could be something very serious going on, but they might be totally fine. Add in old age and significant comorbidities, and I get a lot more nervous. We have a particular population that more frequently has these presentations and they have a language barrier that impairs follow up. On top of that, we have a lot of midlevels who siphon off all simple and straight forward cases so my set gets more skewed and then when they get the weird stuff, they come to me to figure it out. It's incredibly exhausting. I just want some renal colic or vaginal bleeding or an ankle sprain for god's sake! Anybody have an approach that helps with this?

 

[namethatsmell]

Thanks everyone. Im now 6 weeks in. Despite getting good feedback, I am still struggling and have lost weight I didn't have to spare. I think I need to change my cognitive/ emotional approach to get some relief. I would appreciate some feedback.

1. I think I'm expecting too much of myself. In my mind, I'm solely responsible for the health and wellbeing of all my patients and can't miss any possible disease or have any bouncebacks or make any mistakes in general. I realize that is patently unhealthy, but I hang on to it because of a belief that this is what makes me thorough enough to be a good doctor. I guess I'm looking for a more realistic self-standard because the cognitive burden of my current expectations is making me indecisive and possibly could lead to errors.
2. Weird/ vague combinations of complaints. I'm getting way more of these than I did in residency. Things where there could be something very serious going on, but they might be totally fine. Add in old age and significant comorbidities, and I get a lot more nervous. We have a particular population that more frequently has these presentations and they have a language barrier that impairs follow up. On top of that, we have a lot of midlevels who siphon off all simple and straight forward cases so my set gets more skewed and then when they get the weird stuff, they come to me to figure it out. It's incredibly exhausting. I just want some renal colic or vaginal bleeding or an ankle sprain for god's sake! Anybody have an approach that helps with this?

Take a breath, you're right where you need to be. When you're starting out it's OK to be very conservative.

Regarding vague complaints, nobody enjoys seeing those patients. It's what makes our field hard. Giving you an approach is tough because it's so different depending on the vague stuff that patient complains of. In general though, I look at the combination of vitals+chronicity of symptoms+patients contact with the health care system. Doing this can often help get you started and if I'm still concerned I usually arrive a list of 3-5 can't miss things diagnosis. Then, all you gotta do is rule them out rather than try to diagnose them. You don't have to test for everything, you just have to briefly chart how you're ruling things out clinically. Also, seeing patients walk (or observing whatever the relevant functional activity is) can also provide a some measure of comfort that the patient's body isn't exploding from the inside out (CC from last week). If you do this and they have a normal workup and stable vitals during their ED visit they're probably fine for home with the diagnosis of their main symptoms.

Also, it's time to accept the fact that you're very human and will make mistakes. Just like every other human. This can be hard to embrace (I continually have to work at it) but for your own sanity and well being you owe it to yourself to try.

 

[scummie]

Thanks everyone. Im now 6 weeks in. Despite getting good feedback, I am still struggling and have lost weight I didn't have to spare. I think I need to change my cognitive/ emotional approach to get some relief. I would appreciate some feedback.

1. I think I'm expecting too much of myself. In my mind, I'm solely responsible for the health and wellbeing of all my patients and can't miss any possible disease or have any bouncebacks or make any mistakes in general. I realize that is patently unhealthy, but I hang on to it because of a belief that this is what makes me thorough enough to be a good doctor. I guess I'm looking for a more realistic self-standard because the cognitive burden of my current expectations is making me indecisive and possibly could lead to errors.
2. Weird/ vague combinations of complaints. I'm getting way more of these than I did in residency. Things where there could be something very serious going on, but they might be totally fine. Add in old age and significant comorbidities, and I get a lot more nervous. We have a particular population that more frequently has these presentations and they have a language barrier that impairs follow up. On top of that, we have a lot of midlevels who siphon off all simple and straight forward cases so my set gets more skewed and then when they get the weird stuff, they come to me to figure it out. It's incredibly exhausting. I just want some renal colic or vaginal bleeding or an ankle sprain for god's sake! Anybody have an approach that helps with this?

Where I work now, there are quite a bit of middle aged folks. Other hospitals siphon off the elderly weakness and AMS. I think what helps is what others have mentioned--are the VS normal? Are they frequent fliers (makes me less worried they are going to die today)? What specifically did they want me to fix today? I also try to set up expectations at the initial interview--"We may not be able to figure out why you have X, but that's why we will check you out, make sure you don't have anything that's life threatening or that you need to be admitted for and have you follow up with your regular doctor next week." I also tell them they get one thing to be fixed, not 5 things (chest pain, abdominal pain, back pain, knee pain, toe pain, oh and rectal bleeding). Something that also helps is asking them if there is something in particular they are worried about--blood clot? cancer? Because I can address those concerns. And if not, throw the generic lab dart and have their PCP set them up with a specialist for further testing. If they are walking around, have normal vital signs, are asking for something to eat or are on their phones, they are probably going to be okay. Just explain that I may not be able to figure out in the ER why their ankles are swollen for the last three days, but I'll try to figure out what I can with the tests available. If not, send them back to their PCP.

 

[Mbekweni]

Consider being more aggressive about calling patients 1-2 days after you see them. Helps a lot with your confidence in knowing that they are actually not dead at home. Plus it helps with patient satisfaction. Then cut back as your confidence improves. I would call back 2-6 per shift in the following days, now down to 1-2 for those that could have gone either way on the admit/discharge spectrum.

 

[thegenius]

Regarding vague complaints, nobody enjoys seeing those patients. It's what makes our field hard. Giving you an approach is tough because it's so different depending on the vague stuff that patient complains of. In general though, I look at the combination of vitals+chronicity of symptoms+patients contact with the health care system. Doing this can often help get you started and if I'm still concerned I usually arrive a list of 3-5 can't miss things diagnosis. Then, all you gotta do is rule them out rather than try to diagnose them. You don't have to test for everything, you just have to briefly chart how you're ruling things out clinically. Also, seeing patients walk (or observing whatever the relevant functional activity is) can also provide a some measure of comfort that the patient's body isn't exploding from the inside out (CC from last week). If you do this and they have a normal workup and stable vitals during their ED visit they're probably fine for home with the diagnosis of their main symptoms.

Totally agree...and I find myself saying the following in my head (and sometimes out loud too in front of the patient)
"You have an odd set of symptoms, unclear what is causing your problem."
"There might be 20, 30, or 40 different possible explanations."
"However only a very small number, like 5 (or make up a number) are diagnoses that will kill you."
"And my job is to make sure you don't have those 5. I can't do everything. That's why 95% of all the doctors in our country work in clinics."
"I promise I will test for those 5. I just can't do anymore."

Now
1) you gotta make them feel better. Most people have pain, so make sure you take away the majority, if not all, of their pain in the ED.
2) When someone has weird symptoms that don't make sense...I always first think vascular. Because frankly most serious of all medical emergencies are vascular. As long as blood goes to where it's supposed to go, and returns to where it's supposed to return, then you've ruled out the real bad stuff. You can't miss major bleeding, stroke, heart attacks, PEs, dissections, ischemia, etc. Notice these are all vascular emergencies. You can miss the weird infection. Because that infection is not causing hypotension and sepsis (because you wouldn't miss that). You can miss weird Neurologic stuff (not strokes), because most of it is indolent.
3) Pt's love that ****. Especially if they are not educated. The love it when you say "Ma'am the blood is flowing real well to your brain and back.
4) I tell just about every patient "I believe your symptoms! I believe your pain! Something is wrong. But it ain't serious. There are doctors that want to get paid to help you out there! Go see them!"
5) So they leave the ED, their pain is gone or almost gone, and you verify via testing that the blood is flowin' just right.

You'll be fine. I'll tell ya I know where you are coming. People always say "no-one is helping me, where else am I supposed to go?" It was hard at first for me to answer that question. Now I just say "Sorry, I can only do what I can do. And I'm trained to save you from dying."

 

[RoyBasch]

I remember a long time ago I used to think the "Sick," crashing, burning patients were the biggest challenge in EM. I have come to realize that when a patient is really entering one of those common spirals of lethal pathology (hemorrhage, acidemia, hypothermia, coagulopathy, hypoxia, whatever) you know what to do. Those patients intellectually actually become "easy" because they have obvious problems which have a very narrow set of solutions (volume resuscitate with blood products or crystaloid, intubate, ventillate, pressors, whatever).

The much harder patients are the vague constellation of symptoms in a middle age patient with middle level comorbidities that 99% of the time is absolutely nothing but 1% of the time is a dissection, cerebellar CVA, spinal epidural abscess, etc. I think in these patients lies the true art of emergency medicine. They are the hardest patients to master. With regards to picking up the dx, that is a very long conversation based on your training and then subsequent lifetime of experience. But because most of them have nothing, an equally important skill is how you handle those patients.

I think thegenius hit it on the head with this quote:

4) I tell just about every patient "I believe your symptoms! I believe your pain! Something is wrong. But it ain't serious. There are doctors that want to get paid to help you out there! Go see them!"

I find this line to be very helpful: "I believe your symptoms!"

Many patients think if you do not give them a diagnosis, you just think they are full of **** (and maybe you do). But telling them they are full of it only makes them dig in harder and make life for you more difficult when they start insisting on stat specialist consultations and MRIs at 0400 (which ain't gonna happen).

So validate their symptoms. Explain that just because YOU the ER physician don't have a diagnosis doesn't mean one doesn't exist. I agree with thegenius' approach of explaining the importance of follow up and testing not available in the ER while simultaneously emphasizing that the most important threats to life and limb have been ruled out.

By nature of the fact that we see some people who are unreliable, unreasonable, unpaying oafs that will never follow up clinic means they wont be satisfied by that plan. So be it. Embrace that by definition some ER patients are totally unreasonable and cannot be satisfied.

As long as your overall patient satisfaction isn't an outlier in your groups' metrics it won't be an issue.

 

[thegenius]

As long as your overall patient satisfaction isn't an outlier in your groups' metrics it won't be an issue.

In our group the patient satisfaction range is like 5%-95%. And it varies every few months. Hard to be an outlier in that range! LOL

 

[RoyBasch]

In our group the patient satisfaction range is like 5%-95%. And it varies every few months. Hard to be an outlier in that range! LOL

Heh not that I want to validate the BS metrics out there but, what are the guys in that 5% satisfaction range doing?!

 

[thegenius]

Heh not that I want to validate the BS metrics out there but, what are the guys in that 5% satisfaction range doing?!

LOL!! The numbers very every few months. I was > 90% for two reporting periods in a row, then I had one that was ~40%.

I don't think there is much correlation in my mind between patient satisfaction and provider. We all know some providers just hate actually talking to patients - and they tend to have lower scores. And sometimes the n is low. Like the are 10% but only 5 people reported during that reporting cycle.

 

[Psai]

LOL!! The numbers very every few months. I was > 90% for two reporting periods in a row, then I had one that was ~40%.

I don't think there is much correlation in my mind between patient satisfaction and provider. We all know some providers just hate actually talking to patients - and they tend to have lower scores. And sometimes the n is low. Like the are 10% but only 5 people reported during that reporting cycle.

How can you have ten percent with 5 people? Just had one pt with fifty percent satisfaction?

 

[thegenius]

How can you have ten percent with 5 people? Just had one pt with fifty percent satisfaction?

THe last time I saw the numbers was a year ago. I spent about 20 seconds lookin at them. I think our group ignores the numbers now. So I don’t remember the exact details. All I remember was someone had a real low percentage, and their n was small.