Advice to Senior EM Residents (actually, all residents & fellows)

To Senior Residents in EM:

Congratulations on making it to your final year of training! This is certain to be an exciting time. It will also be challenging and stressful. Never forget that the work you do is important to the lives, health, and wellness of so many people, their families, and friends.

There is a great deal to learn and to crystallize during your final year of training, whether you are in your third or fourth year of residency, or in fellowship. To assist with your transition, I share several observations and describe five actions that can increase the likelihood of your success and happiness. There will also be a tremendous amount of information to process after graduating, some of which I address. As much of this information is universal, it will have value for medical students, interns, residents at any stage of training in any discipline, fellows, and junior faculty. A commitment to lifelong learning in health care (especially in EM) has never been more imperative.

Given how changes in the EM landscape are continuous and rapid, my first suggestion is to be present and pay attention. Be present in your interactions with your patients and colleagues. Pay attention to the political climate in EM (at national and state levels), to organizations in EM, and to the business of EM (nationally and locally). Give intentional attention to these areas, in addition to scientific advances in our field. This knowledge will prove relevant throughout your career, which, despite its challenges, will hopefully be productive, lengthy, and satisfying.

As the safety net for health care and for the public, the demands placed on EM and EPs are difficult to meet. Attention to these challenges increased during the pandemic, when the general public and public officials correctly labeled first responders and emergency personnel as “heroes.” Sadly, much of this favorable attention has waned. However, an important opportunity remains for us to rebrand ourselves and our specialty, of which we should take advantage.¹

Given EM’s intersection with so many stakeholders, my next suggestion is to become familiar with the individuals and organizations that influence your career. For EM to thrive while continuing to provide the best possible care to anyone, at any time, for any reason,² hospital and political leaders (with our input and assistance) must focus their efforts on improving key elements of EM practice. These include, but are not limited to, soaring boarding rates,^3,4 lengthy admission times, limited bed availability (in the ED and the hospital), problems impacting ED throughput and efficiency, lack of specialty consultant access, widespread and escalating workplace violence,^5,6 increasing mental and substance use-related illnesses, and the difficulties our patients face scheduling necessary follow-up care. Interhospital relationships and relations with EM and non-EM colleagues, as well as respect for EM within hospital systems, are fundamental to personal and overall success. These relationships must be valued and reinforced. When they are strong, individual EPs and EDs tend to receive greater support from the medical and administrative staff. Our patients, their families, and members of the community also have an important role. They should be encouraged to share their stories with administrators and politicians, through letters, phone calls, surveys, or on social media.

Additional internal and external influences to give careful attention include inherent nuances of the ED and the hospital where you work. Clinical and administrative support in EM and in the ED, as well as diversity, equity, and fairness, are significant factors to consider during your transition to attending staff. Hiring and promotion practices, advancement opportunities, objective pay, equitable scheduling, staffing, and assignments or responsibilities that include activities unrelated to direct patient care greatly impact your work environment. Changes in the leadership of EDs, ED groups, and hospitals relate to income and job security, which may produce stress and anxiety, which likely impact career satisfaction. The corporatization of EM,^7,8 hospital and/or group consolidations, health-care worker burnout and attrition, and workplace safety are getting national notice. Fortunately for EM, national fee structures have started to increase, and surprise billing has received political attention as well. My hope is that attention to these vital aspects of EM will translate to enhanced health-care outcomes for patients, consistently excellent patient care experiences in better ED environments, upgraded safety for everyone in the ED, increased job security, more EM positions, and improved career satisfaction.

Given my expertise with and passion for career planning⁹ and mentoring,^10,11 I’d like to share five major areas which often create problems for graduates in their new positions. Consider these during your final year of training and strive to further develop them. Seek guidance in these areas while EM faculty at your program are available to assist you.

1. Conflict resolution/conflict management (i.e., interpersonal relations) — How well or how poorly do you handle a disagreement or conflict with a patient, family member, colleague, consultant, tech, nurse, director, or administrator? How does your ability to handle conflict impact your responsibility serving as your patients’ advocate? How skillfully can you handle a disagreement with a colleague or consultant that directly relates to patient care (for example, disagreeing with their clinical recommendation after you’ve sought their opinion)? How healthy are your pre-existing relationships, and how well do you establish new (first-time) relationships, particularly during an intense or time-sensitive moment? How well do you negotiate? How well do you “play” with others in the health-care “sandbox”? Communication is key, including verbal and nonverbal (such as body posture, positioning, and gaze), writing or messaging, active listening, and collaborating. EM textbook chapters on conflict resolution and conflict management offer additional background and much-needed tools.^12,13
2. Efficiency — Metrics matter to many people, particularly administrators and hospital leaders.¹⁴ I strongly recommend that you find out which tool and/or company is used for patient satisfaction surveys as early as possible, including the logistics surrounding their delivery and statistical analysis. It is also important to identify which other metrics are measured at your new facility and ED. Commonly collected, monitored, and used metrics include physician time to patient, time to disposition, patient complaints, number of return visits (even though this may be positive due to detailed discharge instructions that are followed), number of labs or imaging tests ordered, number and “appropriateness” of consultants called (which may have nothing to do with your clinical skills), and number or percentage of patients admitted. To some extent, these metrics relate to efficiency and throughput, as does the metric of how frequently the ED “backs up” when you are working (often a gestalt made by others, such as a charge nurse, which may also have nothing to do with your skills). These metrics and perceptions answer the question, “How smoothly does the ED run while you are working?” Hospital administrators and ED leaders pay attention to this and to any patterns that emerge.
3. Billing/coding/documentation — These may not matter to you now (or ever), although they should since they matter to people at your new hospital. Despite their significance, billing, coding, and documentation are frequently not taught well during residency (possibly because many faculty aren’t comfortable with this knowledge or aren’t coding and billing themselves).¹⁵ I encourage everyone to become familiar with and learn the electronic medical record (EMR) system at your new hospital prior to providing direct patient care. Within the EMR, it is critical to accurately record and correctly document those things you are doing and the care you are providing, including necessary interpretations. This generates revenue for your group, for your hospital, and possibly for you (directly or indirectly). Furthermore, appropriate documentation, coding, and billing should improve your job security.
   
   If your group depends on revenue generated from patient care that is reimbursed as the result of documentation, coding, and billing, why wouldn’t they also pay attention to individual metrics related to reimbursement? This is especially true if an ED is losing money, or if you are an outlier compared to your colleagues with respect to billing (and generating revenue). Despite these pressures, do not bill for things you haven’t done, which is illegal. Nor should you perform procedures or order tests that are unnecessary for extra revenue, which is unethical. Granted, documentation, coding, and billing are difficult topics. Gain as much exposure as possible during your training and prior to your new position. I also strongly recommend meeting with the billing company at your new position early on (preferably before you start) and more than once, soliciting feedback about how you are doing and how you can improve.¹⁶
4. Wellness, especially resilience — How are you taking care of your own health and needs? How well are you sleeping? How often are you pursuing hobbies and relationships outside of work?¹⁷ Are you exercising regularly and eating well? Are you smoking, drinking, or relying on medications to help you deal with stress, anxiety, or sleep?¹⁸ Are you comfortable seeking professional help for struggles you might be facing?
   
   Resilience is also a significant part of wellness. How well do you bounce back from a tough case, a bad outcome, an error, a lawsuit, a stretch of shifts, an overnight shift, a personal or family problem, any conflict, or financial stress?¹⁹ Wellness is central to your resilience, and resilience is central to your wellness. Both are essential to your general health and for your overall performance. It’s wise to pay close attention to them at all times, not only when things become challenging. Consider developing a consistent mindfulness practice you can rely on during work and during personal time. Many studies by numerous authors have demonstrated the benefit of keeping a gratitude journal, although I urge you to avoid using social media as your “journal.”
5. Mentorship — Mentors and mentorship have proven to be critical to the development and advancement of professionals at all levels. Seek mentorship. It isn’t necessary to have mentors with similar backgrounds, or shared gender or ethnic characteristics. It is quite reasonable to have more than one mentor, even someone from outside of EM. However, it is best to find mentors who share similar values and desire to help you achieve your goals (not their own). Make and take time to reach out to mentors for advice, wisdom, and help supporting your growth. A mentoring relationship increases the likelihood of success and improves performance outcomes. Greater job satisfaction, faster promotions, higher salaries, and increased productivity are only a few outcomes of having (and working with) a strong mentor or mentors. Discuss with your mentor the best ways to maintain joy and meaning in your work. Gain their advice about work-life harmony (a term I prefer over the phrase “work-life balance”).^20-22

I wish you the very best during the remainder of your training and throughout your career. It is always beneficial to develop new skills, to invest time learning more about topics you might not know as well as you could, to improve efficiency and communication, and to actively pursue mentorship. There is no weakness in focusing on your own health and wellness, seeking advice, understanding your limitations, and being dedicated to continuous learning and improvement.

I have great respect for what you are doing and all that you’ve accomplished so far in your careers. I hope you are proud of your triumphs and achievements as well.

References

1. Gaddis G. Emergency Medicine Deserves to “Re-Brand” Itself as a Cost Saver. ACEP Now. July 6, 2023. Accessed 8/22/23.
2. Zink BJ. Anyone, Anything, Anytime: A History of Emergency Medicine, 2nd ed. ACEP Publ. Dallas, Tx. 2018.
3. Kilaru AS, et al. Boarding in US Academic Emergency Departments During the COVID-19 Pandemic. Ann Emerg Med 82(3):247-254.
4. Kanzaria HK, Cooper RJ. The Unspoken Inequities of Our Boarding Crisis. Ann Emerg Med 82(3):255-257.
5. Budd K. Rising Violence in the Emergency Department. AAMC.org. Feb 24, 2020.
6. ACEP Emergency Department Violence Poll Research Results. August 2022. Accessed 8/21/23.
7. Rizvi S. Exorcising the CMG Demons of Emergency Medicine. Emerg Med News Oct 20, 2020. DOI: 10.1097/01.EEM.0000721172.11584.6f
8. Pines JM, Aldeen A. Questions You Should be Asking About How Your Physician Group Works. August 19, 2023. Accessed 8/21/23.
9. Garmel GM. Career Planning Guide for Emergency Medicine (2nd ed). Emergency Medicine Residents’ Association. EMRA Publication. Irving, TX 2007.
10. Garmel GM. Mentoring in Emergency Medicine. In Practical Teaching in Emergency Medicine, 2nd ed, Rogers RL (ed), Wiley-Blackwell, UK 2013.
11. Garmel GM. Mentoring Medical Students in Academic Emergency Medicine. Acad Emerg Med 2004;11:1351-7.
12. Strauss RW, Garmel GM. Conflict Management. In Strauss & Mayer’s Emergency Department Management. ACEP Publication, Dallas, TX. October 2021, pp 113-132.
13. Garmel GM. Conflict Resolution in Emergency Medicine. In Emergency Medicine: Clinical Essentials, 2nd ed. Adams JG, et al (eds). Elsevier/ Saunders, Philadelphia, PA 2013, pp 1743-1748 (an extended version of this chapter is published on-line at ExpertConsult.com).
14. Doerr J. Measure What Matters: How Google, Bono, and the Gates Foundation Rock the World with OKRs. Portfolio/Penguin, New York, NY, 2018. 
15. Weizberg M, et al. Pilot Study on Documentation Skills: Is there Adequate Training in Emergency Medicine Residency? J Emerg Med 2011;40(6):682-6. DOI: 10.1016/j.jemermed.2009.08.066 (accessed 8/21/23).
16. ACEP 2023 Emergency Department Evaluation and Management Guidelines. Accessed 8/21/23.
17. Murthy VH. Together: The Healing Power of Human Connection in a Sometimes Lonely World. Harper Wave (Harper Collins), New York, NY 2020.
18. Votey SR. It’s Time to Wake Up to the Use of Pharmacologic Sleep Aids by Emergency Physicians. Ann Emerg Med 2019;73(4):330-2. DOI: 10.1016/j.annemergmed.2018.09.035 (accessed 8/21/23).
19. Cross R, Dillon K, Greenberg D. The Secret to Building Resilience. Harv Bus Rev Jan 29, 2021. Accessed 8/21/23.
20. Coates WC. Being a Mentor: What’s in it for Me? Acad Emerg Med 2012;19:92-7.
21. Yeung M, Nuth J, Stiell IG. Mentoring in Emergency Medicine: The Art and the Evidence. CJEM 2010;12(2):143-149.
22. Giesler J. Let’s Replace the Term ‘Work-life Balance.’ Journalism Institute National Press Club. Oct 18, 2021. Accessed 8/21/23.