After 35 years in emergency medicine, you gain a little more than just medical knowledge. The day in and day out, grueling aspects of our chosen field can sometimes be difficult, and so I offer my suggestions for a long and fulfilling career in this challenging specialty. While not scientific, and perhaps not original, and certainly not always fail-proof, here are some of the points that helped me to a long and fulfilling career.
1. Remain humble.
The human body and the illnesses that plague it are complex; there is much we don't know, especially on a limited ED contact. The worst mistakes I have made were the result of rushing to conclusions, or adhering to an inappropriate diagnosis. Avoid jumping to quick conclusions, and be especially cautious when something appears too obvious. Admitting to myself, my consultants, and my patients that sometimes I did not know the answer has helped me numerous times. I found it mentally easier to be unsure, rather than to be wrong. An uncertain diagnosis is better than a wrong diagnosis.
2. Remember that your main goal is not to save lives.
Like most of us, I entered emergency medicine to save lives. There are the occasional resuscitations that turn out well, and they gratify this desire. However, we mostly treat moderate to minor illnesses and many worried well. Repair of a laceration, treating acute pain, talking to worried parents, and reasoning through the symptoms and making a diagnosis may seem routine, but can provide ongoing satisfaction. Feeling frustrated by rote, unexciting encounters while waiting for the next major trauma or resuscitation will breed dissatisfaction in your specialty choice. Treating minor illnesses may prevent more serious complications and benefit patients more than treating them in the end stages of their disease. After all, we treat patients, not illnesses.
3. Treat all patients as an exciting clinical challenge.
Use your history and physical exam skills, and then test as necessary. It is much more rewarding to think, to be a detective and make a diagnosis based on your personal diagnostic skills, rather than looking at laboratory results or CT images. Be cognitive, not just a computer screen monitor. The patients with chronic back pain seeking narcotics are difficult for all of us, but trying an individual approach is worth the effort. Rather than being angry at the encounter and the patient, invest interest in them as a person (even if narcotics are not prescribed). Importantly, it may prevent you from missing a true acute pathology. In essence, take all patients as a learning experience.
4. Don't rush.
This may sound impossible in a busy ED, but a deep breath and a few seconds in a critical situation can help establish the immediate priority, organize resources, and formulate a treatment plan. In other situations, take a few extra seconds with the history; it is amazing what you can learn when you allow the patient a voice. I have found it very helpful to have family at the bedside – ask if they have anything else to add. Often a diagnosis can be made by a comment from someone other than the patient.
Take time with your physical exam; looking beyond the torso may actually produce the diagnosis. Check the groin and legs, look in the ears and mouth. Patients and their family will feel that you are more thorough, and you might find what you were really looking for. Stop by to see your patient more than once – often the repeat exam reveals the diagnosis. That diffuse belly pain just might turn into focal right lower quadrant pain. Repeat interactions can reveal important clues in the history as well – like the patient I was discharging with a tension headache and anxiety asking whether the new gas space heater he's been using might be an issue. Don't rush patients along at the end of your shift – your impressions on your way hurriedly out the door are more likely to be wrong. Take time to be a doctor.
5. Realize you aren't perfect.
This goes with humility. Accept that you will not always make the diagnosis, and realize you will make mistakes. Just remember to keep trying, learning, and improving yourself.
6. Realize you can't save the world, or even every patient.
Not every patient can be saved, nor every problem solved. This includes critically ill patients, as well as the numerous drug, alcohol, and social problems we see. However, performing your best for each patient with whatever resources you have available will, in aggregate, make positive differences for all the patients we see over the years.
7. Try to please patients.
I won't go into patient satisfaction scores. Better than survey metrics is just treating patients as individuals, involving patients and families in their care, and applying your training and knowledge. It's better for your integrity and sanity. I started performing patient call-backs 25 years ago, and it has been immensely gratifying. Patients are so happy for someone (especially the physician who saw them) to check in on them and answer questions. I've had more expressions of gratitude over the phone than in person in the ED. I even believe I've avoided some potential malpractice cases when I called the patient and realized that they didn't do as well as hoped, or that I missed the diagnosis, but was able to discuss it with them.
8. Accept help from all.
Nurses, social workers, aides, and clerical personnel often have information and ideas you never will. Don't ever play down their roles or ignore what they have to say.
9. Keep learning.
Learning helps us become involved in what we are doing, keeps the practice more exciting, and gives us more credibility when interacting with other members of the medical staff. Pick up a journal, reread your textbooks. Expanding your knowledge has obvious benefits for the patient.
10. Keep teaching.
Teaching can take many forms, from explaining a diagnosis to patients to discussing concepts with nursing staff, to formal academic lectures. Teaching and receiving questions sharpens our thinking skills and makes us reflect on what we know (or don't know).
11. Get involved generally in emergency medicine.
Try to engage in medical activities outside your required clinical duties. Attendance at your local hospital medical staff departmental meetings, or presentation at grand rounds provides both personal and system improvements. Local medical societies, EMS, and state and national emergency medicine organizations are also great ways to be involved and learn from other environments, as well contribute to the specialty of emergency medicine.
12. Keep a life out of the ED.
Much has been written about life outside of work, but it can't be overemphasized. Space your shifts, and try not to be a hero working many hours. Make a priority of activities outside of the ED; most importantly, remember family and friends. Keeping some psychological space between the ED and home, such as a drive, a walk, or a nonmedical reading interlude, helps keep the stress of practice where it belongs.