Gentle Reader:  Several months ago a fine young physician named Sajid Khan contacted me.  It turns out that he actually read my blog (surprise!) and wanted me to contribute a piece to his upcoming book about things newly-hatched ER docs should know about the real world.  I was humbled to be asked and I went a little crazy.  So crazy, in fact, that after he judiciously cut all the weak material (which, of course. I thought was the funniest but I have issues), he graciously consented to let me use the leftovers for my blog.  Some of this might seem familiar, but probably 80% or so is new.  And I miss Miss Manners.  

What I’ve Learned

(with apologies to Esquire magazine)

Howard Rodenberg, MD MPH

Getting out of residency is a transition, to be sure.  You’ve gone from a pimply-faced pre-med with a Star Trek poster in your dorm room (Nerd Alert), to a med student with an AMA bumper sticker on your parent’s old Buick, to an intern (“I’m a doctor, really I am”), and finally to a resident physician in the specialty of your choice.  And now you’re on the cusp of becoming an Attending, one of the folks who gets to wear the long white coat at the more prestigious academic institutions, which is really just a badge of insecurity that says “I was too frightened to leave.”

Yes, this is what you’ve dreamed of; this is why you gracefully accepted all the required floggings for the last decade or more of your life.  (Medical Education Motto: “The Beatings Will Continue Until Morale Improves.”)  You’re the one in charge.  You’re the one they come to see.  You’re the one who stands tall in the saddle, steaming cup of coffee in hand, while nurses and techs and paramedics and most of all patients cling to your every word.  Make it so.  It’s gonna be great.   Huge.  Trumpian.  The Best Thing Ever.  Which makes it all the more perplexing when you get into the real world and find that your vision of the Attending Physician is a lot like the word inconceivable as defined in The Princess Bride:  It does not mean what you think it means.  In the community, everyone is an Attending Physician.  (Yep, even that guy.)  And Community Hospital Attending Emergency Physician means Worker.  Not Queen, not Drone, not even Larvae to be feted with royal jelly.  Worker.

The simple fact is that being in The Real World is tough, more so than residency, though in a new and terrifying way.  At least in residency you know who your enemies are because they lie close to you, lurking around every corner and watching your every move.  In The Real World, you’re being observed from afar, held to standards you don’t know about by people who don’t know you and can’t do your job.  And you can’t see them, for they live in E-Suites and insurance skyscrapers and government palaces and consultant office parks many moons of travel from where you pitch your pup tent of a career.  How-to guides like this one are full of invaluable tips to help you navigate this new ocean.  You’ll learn about contracts, group structures, 1099 Forms, how many donuts you can expect to find at a Medical Staff Meeting, and other useful things that your former Professors, most of which have NEVER LEFT the warm and cozy confines of the ivy-covered walls, find inconceivable.  (And yes, this time the word means exactly what you think it means.)

But let’s not talk about clinical practice, and let’s not lose ourselves in visions of what goes on in the Administrative Playgrounds.  Let’s talk about you.  Specifically, how you will change over the next decades, what you will feel, who you might become, and what to do about it when you do.  A career in Emergency Medicine will change you, and not necessarily for the better.

Here’s what you really need to know, and what I wish someone had told me.

Emergency Physicians lie.  A lot.  You will too.

I would certainly agree that, at least in theory, Honesty is the Best Policy.  But there are sometimes better and worse ways to be honest.  As Emergency Physicians, we develop a skill at obfuscation, which is the first step down the slippery slope of deceit.  We obfuscate because it generally serves to keep us out of trouble by telling the truth.

The Lie of Obfuscation occurs when you’re trying to communicate a message in a way that won’t get you an administrative e-mail (“Nastygram”).  For example, let’s take a hefty individual complaining of chronic back and knee pain, which you know will never get better until they drop the poundage.  But instead of saying, “You have this pain because you’re fat and you need to lose weight,” you say, “You know, you’re kind of a bigger person, and that might be part of your problem.”  Technically, at 6’1” in a nation where the average male stands 5’9 ½”, I’m a bigger person.  I also weigh 150 pounds fully decked out after a box of Twinkies.

Closely related is the Accessory Lie of Withholding, also known as Applying the Internal Filter.  Examples including not telling patients they are aesthetically displeasing oxygen thieves, their babies are ugly, that they really should have sprung the extra dollars for the good tattoo parlor, that the only good genitals are unexposed genitals, or that their very existence makes a convincing argument against Intelligent Design.  This is also the one where you don’t say to the patient on public assistance who is complaining and threatening to refuse to pay, “You’re not paying for it anyway.  I am.”  (The inability to consistently tell the Accessory Lie of Withholding is probably why I work a lot of night shifts, avoiding the daylight presence of Administration.)

Then there’s the Lie of Feigned Ignorance.  Doctors, nurses, and other health care people know a lot.  Most of that which you know you will tell patients.  However, shortly in your career you’ll begin to notice that you do so in a way that’s particularly fun for you, especially if it’s juicy stuff.  For example, if the patient’s urine tested positive for methamphetamine after they had told you they don’t do drugs, you could just walk into the room and say, “Your urine has meth in it.”  That’s boring.  Or you could sit down and say, “Just remind me.  I think when I asked about drugs, you said you didn’t do any, right?”  When they confirm that statement, then you get to say, “Well, your urine tested positive for meth.  How do you think that got in there?”  Then you watch them come up with a story.  This is an especially fun conversation if there are others in the room, for if they are there I always assume the patient’s okay with them hearing everything I have to say, else the patient would have shooed them out.  It works especially well with positive pregnancy tests and the diagnosis of STD.

Most often, though, the things you lie about knowing are bad.  If a patient shows up with three weeks of painless jaundice, we all know it’s pancreatic cancer and things will not go well.  We will get a CT scan, and it will show a large mass where the pancreas meets the biliary tree, and more likely than not the  liver will look like a piece of swiss cheese from metastatic tumor.  But when you discuss the results of the scan, you will find that you don’t say that the patient has cancer and bad things are about to happen.  If I do a thoracentesis (as we old ER docs used to before radiology figured there were dollars in it), and the fluid that comes out is bloody, that’s cancer.  I won’t say that, but I know, and you will too.  If there’s an infection raging through the frail body of someone’s elderly parent, you’ll say that her condition is serious and we’ll do all we can to help.  You won’t say you know she’s going to die.

It’s certainly not that ER docs aren’t able to give bad news.  We do it all the time, especially when death happens suddenly, and are probably so fluent with it that it seems rehearsed. But when it’s something like cancer, or overwhelming infection, or an incapacitating stroke, we often don’t have very many answers for what is likely to be asked, and you’ll hate adding more fear by not being able to provide knowledge or solace.  Definitive diagnoses are best delivered by someone who is part of the team providing continuing care.

The worst lie you’ll find yourself telling is The Lie of False Hope.  At the end of life, or in times of critical illness of injury, all the tools are in the hands of the physician.  The only thing the patient has left to work with is hope.  Hope that they’ll get well, hope that the medical system won’t fail them, hope that their deity of choice will see them through, hope that their friends and family will be there with them as they go into that dark night. The Lie of False Hope is to give hope where there is none.  What makes this lie worse is that often the patient knows that you’re lying, but accepts what you say in an effort to postpone contemplating the inevitable.  But to give hope where there is none, so death comes as surprise; to pretend your efforts will mean something when you know they’re really just for show?  Playing the game of Medical Theater is the worst lie of all. And yet we do it every day.

One last note:  The important thing is to lie only at work.  Don’t do so at home.  I lost twenty years with the woman I love because when I was young and a newly-minted doctor with money, I lied to her about dating someone else.  It’s not good.  Twenty years apart.  Twelve shifts a month for twenty years.  That’s 2,880 shifts, and more each month when I was also paying alimony and child support.  Lying is not a very cost-effective way to live.

Learn to hang crepe

I used think there’s nothing worse than to walk into a room, where a family has been nervously awaiting word on a loved one, and have to tell them their friend or family member is gone.  I bothered me when I was new at this game, but now it’s become a routine.  I’ve found my own way to tell people bad news, just as you will as well.  The one thing you can’t do is pussyfoot around it.

But there is something you can do to make the blow easier, and that’s the hang crepe.  In Victorian times, a household in mourning was identified by a ribbon or bow of black crepe hung on the doorknob, and the clothes of those in mourning were trimmed with crepe as well.  So when you “hang crepe,” you’re preparing the family for what, based on your knowledge and experience, is inevitable, but for them a dreaded fear.

Whenever possible, have someone do this for you.  If you’re running a code, ask a nurse to go tell the family that things are not going well several minutes before you deliver the news.  If you’re at one of those hospitals that allows families to watch codes, make sure that before they get into the room have someone tell them about the sights, smells, and sounds in graphic detail, how long we’ve been working without success, and that the doctor may ask if it’s okay to stop.  All of these help soften the final blow when you deliver it.

This is also important when the patient is critical but not yet dead.  When you talk to the family, remember to say that we hope for the best but expect the worst, but we’ll do everything we can to help.  Then be sure to outline exactly what “the worst” will be.  If the patient survives, you’re a miracle worker.  If they die, you’ve told them in advance.  Win-win either way.

You only remember the ones who came in talking and left dead

You will see thousands of patients in your career.  Most you won’t recall whatsoever.  Some you might remember when prompted because it was an interesting story, an unusual diagnosis, or because you managed to pull a rabbit out of your…umm, right.  The only ones you will remember without promoting are the ones who came in talking and left dead.  You remember those because no matter how inevitable the death was (as it is in nearly all), it happened on your watch, and we’ve been taught that this is failure.  Success is fleeting.  Failure scars.  If you can keep the number in the low double digits, you’re doing okay.

They have names?

Remember that talk in medical school about how patients are more than their physiology?  How each of them is a unique individual formed by a milieu of culture, beliefs, family dynamics, and education?  Can you recall learning how illness or injury is really the culmination of a story, and that story deserves to be heard?  And how asking open ended questions, and allowing time for the patient to respond in his or her own way, is the best way to build the rapport needed for effective care?

It’s all absolutely correct.  And it’s probably the first thing that goes in the active practice of emergency medicine.  Under constraints of time and volume, and ever-increasing demands to sacrifice the former for the latter, you’ll find that the only way you can patients apart is by room number and chief complaint.  Instead of going to see Mrs. Jones, you’re picking up the clipboard for the Chest Pain in Room 2.  And once you’re there, and you ask when the pain started and she begins what’s probably a delightful tale of baking cookies for the church supper two nights ago, you’ll find a (polite) way to cut her off and direct her towards yes or no questions.  And with the patient who has multiple complaints, rather than providing holistic, person-centered care you’ll find yourself saying, “What is the one reason that brought you to this Level 2 Trauma Center tonight?”  Don’t feel bad.  It happens.  And it makes those moments s when you can build a rapport with a genuinely fun and interesting patient all the more valuable.

(One tip on yes or no questions.  If you ask the patient a yes or no question, and they have to think about it, the answer is always no.  No “maybes” in the ED.)

In the ED, kids ARE little adults

This is one of my pet peeves. (Someday I want to get a dog and name it Peeve.)  Most new ER docs are terrified of taking care of kids.  We’ve been trained that way.  We’ve been told by pediatricians that only pediatricians know how to care for children.  They conduct special courses to teach us how to care for kids, but also to remind us how woeful we are when we do so.  Many of us did our pediatric ER rotations during residency in specialty pediatric hospitals, where the message of the uniqueness and exclusivity of children, and of pediatric caregivers, is reinforced.   The overall messaging is constant and consistent.  You can’t take care of kids, because kids are NOT “little adults.”

There is no question that in the long run, kids have different needs than adults.  But in the ER, kids are ABSOLUTELY little adults.  Why?  Because care still follows the ABC’s.  Perhaps even more so, because in kids it’s AAABC (AAA means that it’s Almost Always Airway).  Drug doses are different and the veins are smaller, but the same principles still hold. We adapt all the time for the elderly, the gravid patient, the ones with chronic disease.  All we do by reinforcing the myth that kids are special and unique is to convince physicians, nurses, and paramedics that their efforts at care are doomed to fail.  In reality, at 2 AM in your ED, kids aren’t really any different.  Except that because they haven’t learned sick behaviors, nor how to lie, they’re more genuine.  And quite often more fun than dealing with their parents.

People are surprising hard to kill

No essay here, just a notation.  I’ve made wrong decisions and judgement calls during my career.  You will, too.  But somehow patients survive our best (hopefully inadvertent) efforts to knock them off.  Take comfort in that.

Dinosaurs know things

Twenty-five years out of residency, a physician can claim dinosaur status.  Value your dinosaurs, because they know stuff.  Do you know how to do a diagnostic peritoneal lavage?  A thoracentesis?  A paracentesis?  A culdocentesis?  Can you read a plain cervical spine film or an abdominal series?  Can you look at an IVP? Can you convince a surgeon to admit an appendicitis case without a CT? Can you do a central line without ultrasound guidance?  How do you intubate without sedatives or paralytics?  Have you ever done a blind nasotracheal intubation and dodged flying mucus from lodging within your flowing locks of large 1980’s hair?  (That includes guys as well.)

These are all things I can do.  I don’t say this as bragging, but as a function of time and circumstance.  I trained in an era where advanced imaging was limited to an 8-bit CT scan of the head, and you got that only by convincing the attending radiologist to get out of bed and come to the hospital to read the film.  Obstetrics was just starting to use ultrasound on a frequent basis.  It was a world of clinical diagnosis, where most everything was history and exam.  We learned to fly by trial and error.  Most times it worked.

There is no doubt that today’s graduating EM resident knows more than I did, and probably more than I still do.  When I look at a bedside ultrasound, it looks like someone took a chalk drawing on a sidewalk and poured a bucket of water on it.  I see nothing but a blur of gray.  I’ve gotten pretty good with head and CT scans, but I’m bad with chest and abdominal studies unless there’s a pneumothorax, a pleural effusion, a Swiss cheese liver, or a mass the size of a cantaloupe.  We need you to teach us what’s new, and help us through the maze of bedside technology.  But dinosaurs often know ways around things that you’ve been taught as dogma.  Not because we’re smarter than you, but we had to do the same job without the toys.  And if the particular dinosaur has been around an institution long enough, he or she knows the political land mines, and might be willing to tell you before you blow off a limb.  Maybe.

(It should be noted that we really do look better and smarter than you during computer down time, because that’s our era.)

We’ve also been around long enough to learn that Emergency Medicine is one of the most static, and the most cyclical, of the medical specialties.  ED care has always been about triage and the ABC’s.  It still is.  While technology has revolutionized the vast majority of medical care, ER practice is still all about the history, physician exam, risk assessment, and disposition.  (I think that most ER docs can figure out what needs to happen within the first several minutes of a patient encounter.  Labs and x-rays are really for patient reassurance or another clinician’s use.)

Have there been advances in ER care?  Of course.  But each advance eventually circles back around to where we were before.  When I first took ACLS over thirty years ago, the core lesson was all about the need for early CPR and early electricity to enhance long-term survival.  Since then, we’ve gone through mechanical CPR, IVC-CPR, vest CPR, SCD-CPR, and no ventilation bystander CPR.  We’ve moved from a model of direct cardiac compression to a thoracic pump model.  We’ve realized that rescue breathing is really just a CO2 delivery system.  We’ve run through high dose epinephrine, dropped lidocaine, added amiodarone, dropped bretylium, added vasopressin, and now we’re cooling patients down if they survive the initial episode.  But at every lecture I attend, the message remains clear; the only thing that really matters in long-term survival from cardiac arrest is early CPR and electricity.  Ditto with sepsis, where for years it was all about fluids, antibiotics, and the occasional vasopressor.  Then we had the sepsis bundle with CVP measures, arterial lines, venous oxygen assessments, steroids, and probably some garlic and wolvesbane thrown in for good measure.  And guess what?  Outcome studies still show it’s all about fluids, antibiotics, and the occasional vasopressor.

Dinosaurs also understand that the tincture of time and elixir of neglect is often the best care.  You can learn from them when not to do anything.  They also know that despite advances in scientific medicine 70% of what we do is still voodoo, unsupported by double-blind studies or bench research.  For years, I wore a voodoo bracelet I bought in New Orleans during my shifts to remind me of this.  You should too.

(Oh, one other thing.  Dinosaurs think all new grads are snowflakes.  Limits on how many patients you can have on a service?  Night floats during internship? Work hour restrictions?  24/7 attending supervision? Making more than minimum wage during residency? Signing bonuses and student loan repayments?  Please.)

Caring is conditional

We all went into medicine because we wanted to help people, right?  It wasn’t all about the money.  (At least that’s what everyone who makes more than we do says.)  We are physicians because we care.

Here’s the dirty little secret.  When it's busy, when people are demanding, and when nothing seems to be going right...which are more days then you’ll care to recount in a hectic ER...you won't have time to care.  You’ll find yourself in a mode where your thoughts are more on “moving the meat” and keeping up your end of the workload rather than being open and compassionate to one and all.  You’ll be focused on throughput times, customer satisfaction, charting, and defensive medicine.  I plead guilty to being this way myself.  When I walk into a room and say, “What can I do for you?” to a patient and family, what I often mean is what can you tell me so I can get you out of my ER, and off my hands, as fast as possible?  Or what can you tell me that is going to mean you stay for a long time and jam up one of my assigned rooms so I don’t have to see as many patients?  I hate being that way, but it’s my reality, and it will be yours, too.

Does this mean you’ll never care again, that this part of you is lost forever?  Of course not.  One of my practice partners likes to say that after years in the trenches, we have “selective caring.”  You take the caring you would have shown to people who aren’t worthy of it and double, triple, or quadruple up on those who really need your help.  (I use the word “worthy” on purpose.  Make no mistake about it…your caring and concern, and the emotional energy you invest in the doctor-patient relationship, is a privilege to be won, not a right or entitlement for all.)  Given that the vast majority of patients use the ER for primary and chronic care, and that the ED is the safety net (or wastebasket) for society and certainly the dumping ground of our health care system, you’ll bottle up that caring and compassion for most while looking for opportunities to let it out.  In the process, you’ll find that your mindset changes from “What’s your emergency?’ to “Prove to me you’re sick.” It becomes your own emotional triage tool, helping you to screen for those patients where your time, caring, and compassion can lead you to those rewards of the heart that brought you to medicine as a career.

This attitude shift, while inevitable, is nothing to be proud of.  It’s probably a sign of burnout as well.  But it’ll happen, and it’s not you. It’s the system, and until the way we use emergency services changes no amount of meditation, yoga, exercise, or anything else we’re advised to do under the guide of “physician wellness” will make a difference.  Really, it’s not you.

It could always be worse.  You could be a Hospitalist.

You know your friendly Hospitalist.   That’s the Community Hospital name for the Internal Medicine residents who didn’t want to do a fellowship, the folks who do everyone else admits and provide inpatient care.  The value of the hospitalist to the health care system depends on who you ask. If you’re inquiring of health care theorists, their familiarity with acute inpatient care makes them more likely to provide efficient, high-quality, low-cost care than physicians who only do hospital work part-time. If you ask the bean counters, hospitalists provide a service to the community physicians who will then drive their patients, and their revenue, to that hospital that provides that service and relieves them of after-hours duties. If you ask most physicians (off the record, of course), hospitalists exist so they don’t have to get up at night to see patients nor make hospital rounds during the day, taking time away from the more revenue-friendly outpatient practices and procedures. And if you ask an ER doc, the hospitalist is the one guy thankfully even lower than you on the food chain, the one for whom even your problems roll downhill.

To say that is not to disparage the hospitalists in any way. The vast majority of physicians I know who’ve chosen this kind of practice are good, smart, caring people, who provide excellent care in often the worst of cases and social settings. They accept anything and everything that needs admission. It also means they admit anything we can’t get rid of, even if it doesn’t really need to stay. As you’ve already gathered even at this early stage of your career, there are a lot of people who come to the ER and simply don’t want to go home no matter what. And then there’s the ones who are sent into the ER by their own doctor because the doctor doesn’t want to deal with them anymore.  So the patient gets sent them to the ER with a request that they be admitted while the primary care provider prepares their 30-day notice, copies their records, and places them in a manila envelope by the receptionist desk.

(For the record, when that happens and you meet the patient, you usually understand exactly why the doctor did it. ER Rule 84 J, Subparagraph 2: “If you say your doctor “fired” you, there’s usually a good reason for it. Subparagraph 3: “If you say you fired your doctor, see Subparagraph 2.)

So the hospitalist is the final link in the chain. When the patient genuinely needs to be admitted, or else just refuses to leave, they’re the ones who get the call. Because they are always there for you, and are going to bail you out in the end with both that critical patient who needs hours of one-on-one care as well as that Marvin K Mooney who Won’t Go Now, you want to be their friend. Still, there are tricks. You figure out which ones want what tests done before taking an admission, so you speed up the process when you can.  Hospitalists who are nicer to you when they receive the 3 AM call get the more pleasant patients (preferably unconscious or intubated, as it makes the History of Present Illness so much easier when they can’t talk.)  If it’s fifteen minutes before the end of their shift, you learn to stall just a bit and give the patient to the next one up. But no matter what, you always apologize profusely for any admission unless it’s so critical a case that you sound stupid in your haste to atone. And whenever possible, make sure to say that it wasn’t your idea to admit the patient, but that of the patient’s own physician and you’re just doing what he said.  It’s good to unite against a common enemy.

Someone told me long ago that ER doctors will never have other physician friends, because when you call another doctor in the middle of the night it’s never to ask if they want a beer over breakfast. Yet hospitalists and ER docs tend to get along more than most. I won’t say we’re all best doctor friends, but if it’s lonely at the top it’s nice to be chummy at the bottom. Hospitalists need us to skim off the top. We need them to rake out the bottom. And nobody else wants to get out of bed a moment too soon.

The “Q Word” is real. Don’t say it.

 Again, no explanation required.  Just don’t.  And ostracize those who do. 

There’s no rewards for courage

If something violent goes down in the ER, your job is to get away.  There are people who handle these kinds of things.  They are called Security and Police.  They are not you.  Leave.

If you’re feeling bad about yourself, call a physician recruiter.  You’ll feel special.

The worst possible phrase in the English language is “Remember that patient you saw last night?”

This question is always a disaster-in-situ.  There’s a storm of criticism and second-guessing headed your way.  And if you’re unlucky, it will be followed by a lawsuit.  Over the course of your career, you will get sued, and settlements will be made on your behalf.  If your attorneys think you’re wrong, it will be settled early.  If you’re in the right, it will be settled later, when the cost of defense is more than the cost of the payout.  The process has nothing to do with the truth, and either way it scars.  You will feel every emotion in the book as you go through the process of discussions, depositions, and discipline.  It is an experience which provides no positive good and results in a loss of clinical confidence and a more costly and time-consuming practice of defensive medicine.  Patients are now potential plaintiffs, and everyone is suspect.  This gets worse over time, as you learn of more physicians who are abused and victimized by litigation, and as you recognize that other physicians are driven by dollars to indict their peers.  But as I’ve come to learn, unless you’re losing seven-figure verdicts it’s simply a cost of doing business.  Try to view it as such.  And recognize that because the accusations hit you in your soul, you can’t.  Ever.

Nothing good ever happens on hospital e-mail

See above.  

Your lifestyle will expand to meet your income

Remember how you promised to live frugally and pay off your student loans before doing anything crazy with your hefty post-residency salary?  That was a lie.  People will fall all over themselves to give you “preferred payment plans” and “guaranteed low credit rates” and “special physician mortgage financing” once you have that MD or DO after your name, and you won’t be able to resist.  Before you know it, that bathtub of sign-on cash is gone, and you’re looking for extra shifts at the prison infirmary.  Admiral Akbar was right.  It’s a trap.  I fell into it.  Don’t be me.

Magazines

Less obvious things about you will change as well.  You’ll find yourself reading different magazines.  No more Muscle and Fitness, no more Vogue.  Now it’s old National Geographics and Highlights for Children left over in the waiting room.  (“Goofus gets angry that he has to wait in triage and says he knows the CEO; Gallant is grateful to be told the wait time is four hours.”).  Or maybe People or Cosmopolitan, strewn about the staff lounge which you scan to see which celebrities have fibromyalgia (Kate Gosselin, I KNEW it!) or to read about the “Ten Hot Sex Tips You Should Know” and realize that at least six of them will cause a 3 AM visit to the ER.

Diet

Your traditional medical school and residency diet, affectionately known as the Five C’s (coffee, cola, chocolate, candy, and chips) will expand to Ten.  You will add cheese, carrots, and celery, all of which are found in diced or cube form on the platter you’ve brought from the grocery as your contribution to Christmas Dinner because you’re not giving up one extra moment of sleep to actually cook something before your shift.  You also bring cheese and veggie platters for Christmas Eve Dinner.  And New Year’s eve.  And Thanksgiving, Halloween, and when your best night nurse is transferring to days.  The Ninth C is chicken (fried only), which can be used as a substitute for turkey when you really want to make a statement of affection for your ER crew.  (The Tenth C is cake, but that’s usually a nursing duty.  Check your job description.)  In terms of actual cooking, you are allowed to purchase a Crock Pot for the purpose of melting Velveeta and Ro-Tel or heating Little Smokies in the break room while you’re working the patient load.  But don’t get carried away and actually make something, or they’ll expect more of the same.  Five years of being on matzah ball soup duty for Christmas Eve and Easter (“The Official Shifts of the American Jew”) taught me that.

Revel in your white hat. 

Emergency Physicians bask in the joy of righteous indignation.  We are there...the only ones there…for anyone, regardless of race, creed, color, sexual orientation, socioeconomic status, nature of their complaint, hygiene allergy, or intrinsic unpleasantness.  No other physicians do what we do for so many so often and so well.  We are the Mother Teresas, the Hard Rock Cafes of Medicine existing to Love All and Serve All.  There’s something very noble about that, especially if you’re the only one awake keeping the community safe at night.  The feeling doesn’t last once you recognize you’re expendable, but moral superiority helps you keep going in the short run.

Use silent profanity.  It makes you feel better.

True confession.  My vocabulary has not become more elaborate and refined with the wisdom of age.  I’ve become more vulgar, more guttural, more “foul than fair” in my choice of words.  It’s how I deal with the anger that inevitably comes with years of unceasing demands to do more for more with less and less.  (That’s the best politically correct way I have to express everything I dislike about clinical emergency care.)  Every time I pick up a chart of patient with a chronic complaint, a snot-nosed kid, a headache, a back pain, anyone who I’m able to see through the patient windows eating Cheetos or talking on the cellphone, I swear up a hurricane in my head.  It helps me deal with my anger and frustration at not actually being an Emergency Physician, a way to get it out of my system so it doesn’t show up when I go to the bedside or present a month later as an upper GI bleed.  Profanity out loud causes problems, but profanity for yourself can be lifesaving.  Don’t feel guilty if you do it.

Besides, a certain level of comfort with profanity can actually help your friends.  I have a colleague named Sam who is truly one of God’s good people.  Not only will he not swear, but he even has trouble describing the concrete structures we use for hydroelectric power.

One night, he’s checking out to me, and he’s trying to explain how this particular patient was frustrating him.  I could tell that he simply couldn’t use the word that would best express his emotional state.  Because I am the Mensch of the Flatlands, I said, “Sam, I know you want to say (something that rhymes with duck), but I know you won’t.  So I’ll do it for you.  In fact, any time you feel like you might want to try to say (something that rhymes with duck), call or text me and I’ll do it for you.”  I always keep my phone on when he’s working in case I’m needed.  Just the kind of guy I am.

Oh, I almost forgot.  There are two times in the ER when you are allowed to use full language.  One is when the patient is constipated, because telling someone that they’re full of it is not an opinion, but an objective statement of fact.  The other is when the patient directly insinuates you have an unnatural relationship with your mother, at which point you are allowed to explain that, “My name is DOCTOR (rhymes with Brother Tucker) to you.”

Only Mourners and Complainers know your name.

I was recently on a flight from Chicago to Kansas City and fell asleep before takeoff. When I woke up, I had already missed the beverage service. I walked up to the front of the plane, where the flight attendant was eating her lunch, some kind of plastic-encased salad. I asked her pardon for the interruption, said I was sorry I missed the service, but wondered if there was still a chance I could get a Coke.

She glared at me and told me in no uncertain terms that "I'll think about when I finished" with an expression that indicated she was not simply making a joke. The message clear, I went back to my seat. Thirty minutes later, when she came by to pick up the trash, she reminded me that she had not had time to meet my request with smile that let me know whose work ethic was running the show, and it wasn't Customer Service.

This is not the only flight I've ever taken. It's not the only flight attendant I've ever asked for soda after sleeping through the initial service. But it was one of the few who was genuinely rude. It's reinforcement that the good and the pleasant becomes routine, and only the bad stands out in your mind.

Your image of the physician probably started the same as mine. It's the kindly doctor from the Norman Rockwell Post covers, your own family doctor who cared for you in a time of need, or genteel portrayals of Dr. Kildare or Marcus Welby, MD. Maybe your media influence was from a younger generation, like Dr. Fiscus, Dr. Ross, or Dr. Grey.  They have become your models not only because of their inherent virtue, but also from consistent exposure. You see them at least once a week, and more often in reruns.

In contrast to that continuous soothing physician presence, Emergency Medicine is a one-night stand. If you're a player, you only remember the bad ones. Everything else fades into a joyous blur of hedonistic memory. Similarly, the vast majority of your patient encounters will be pleasant and routine. You will not remember them, and the patient will not remember you. On the other hand, if the encounter has gone badly and the patient has gone sour, or there's been a confrontation with the patient, friends, or family, they will remember you.

Knowing that you'll never be hailed as a life giving savior may be hard to handle, especially since we've been indoctrinated to believe that we'll receive the requisite accolades all through training. It was for me. I was pretty sure I was going to SAVE A LIFE, walk out of the room into the Family Circle, and simply absorb voluminous praise. The fact is that in a crisis, the patient and family will be in such a state they will not remember who you are. The doctor they will remember is the one who spends time with them on a daily basis, caring for the patient in the hospital, talking to family and friends. They'll remember that person as the one who redeemed the patient because of the constant exposure. Even though what you did was probably the life-saving moment, you are simply background noise to the acute event.

Is there an advantage to the anonymonity that makes up for the fact that your glory is dispersed to those less worthy? Well, you can go to pretty much anywhere you want to and not be recognized, especially if a sweat shirt is involved. That's not a bad thing, and it's something that like fine wine, gets better with age.

Normal people are fascinated and repelled by what you do.

After the next bad night shift, offer to take a few of your staff out to breakfast. Find the most crowded and popular place you know. Start talking about what went down the night before. Spare no detail. Then look around you. Have the tables around you cleared, and is your group now sitting in the middle of a void?

Of course you are. Nobody wants to hear what you do for a living on their own time. Your conversation disturbs their appetite. But they want to hear all about it on your time, at a party, at the mall, on the phone.  “What’s the weirdest thing you’ve ever seen?” is a polite way of asking a question you’ll get every time you meet someone new and at every family gathering.  The easiest way to deal with this is to come up with a standard response.  “I could tell you, but I’d have to kill you” has been used, and making an obscure reference to patient privacy, while valid, is simply unsatisfying.  I;ve taken to simply saking my head and saying, “I’ve seen…things…” with downcast eyes while slowly turning away to the bar, where no one will ask you anything except if you want a lime with that.  The fact that the worst thing you’ve seen is not a mangled trauma victim but the man self-pleasuring while viewing the Heart Healthy Lifestyle video in Room 14 is beside the point.  The idea is to shoo them away, at least for the rest of the evening.

Administration never comes out at night.

Neither does the Joint Commission nor Human Resources.  Choose your shifts accordingly.

It’s a job.

It used to be accepted that medicine was a calling, much like a religious vocation.  The training was hard, the hours were long, the responsibilities were great, but the rewards were greater.  A calling also implies hardship, self-sacrifice, a giving of your life to the service of others.   Medicine is not unique in this regard, to be sure…people are called in many different ways…but because our calling is the care of our fellows in their hours of greatest need, medicine has been exalted.  There’s a reason every mother wants their child to be a doctor.

I still believe that for most of us, medicine started out as a calling.  We go into this because we want to do good things for good people, and because we think that when you do so, good things happen to you in return.  It’s an ever-expanding snowball of happiness. 

While I still cling to the idea that medicine is a calling, I’m not so sure it’s a profession.  The book definition of a profession is an occupation that requires prolonged training and a formal qualification.  But implicit in the way we sue the term is a degree of autonomy, of allowing the individual to use their skills and training in unique and innovative ways to determine their conditions of work and to accomplish a task or goal within the standards established by his or her professional peers.

That key criteria, autonomy, is not the case in Emergency Medicine.  We do not work for ourselves, but for hospitals and contract groups.  Our work conditions are determined not by our peers, but by administrative bodies outside our scope of practice or influence.  Our measures of success are less related to the quality of our work than to meeting abstract metrics unrelated to patient care. Our standards of care are determined not by our peers, but by a punitive system of litigation whose demands exceed our capabilities.  The person who works under these conditions doesn’t sound like a professional.  It sounds like someone who has a job.

(In fairness, many physicians would tell you they feel the same.  I’ll grant them their feelings, but all fo their grievances are magnified in the 24/7 pressure cooker of the ED.  There’s also one additional key difference.  Other physicians are still able to maintain some control over their workday through their ability to schedule, refer, and defer.  We have no such option, and as such are totally at the mercy of the winds of the day.)

The hardest part of life as an emergency physician is accepting what you do for what it is.  It’s a job, no more or no less.  Recognizing this is at first disheartening.  It contradicts everything you’ve ever seen, felt, learned, or believed about the role of the physician, and everything you saw yourself becoming when you started the journey to doctorhood all those years ago.  It sometimes takes years to figure this out.  But when you do, it’s an incredibly liberating moment.  Here’s why.

Corollary 1:  No commitments

Despite all the rhetoric you’ll hear on the recruiting trail, emergency physicians are rarely seen as valuable assets to a hospital or health care system.  Let‘s be frank.  Hospitals don’t really fret about the quality of the medical care provided in the ER.  They care about customer service, but that’s not the same thing.  They worry about clinical quality only to the point where it keeps the hospital out of legal or regulatory trouble.  Hospitals vest interest and commitment to physicians who generate referrals and revenue.  We do neither.  So while the hospital is interested in having a body in the ED to dispense smiles and cheer, it is not interested in nor committed to you.  Ask anyone who’s been through a contract change, or had their independent group eliminated by a hospital opting to enroll physicians as employees.  It’s true that active participation in hospital committees and medical staff politics may serve to stave off the wolves.  But your r allegiance to the hospital, your years of dedication and service, mean nothing compared with the need for the new CEO to demonstrate he’s an agent of change, or for the CFO to bring a few more dollars into the C-suite. And if you choose to stay, you’ll likely have your salary and benefits “low-balled” as a reward.  It’s all about the Golden Rule:  Whoever has (or wants) the Gold Makes the Rules.

So why should you feel any long-term commitment to the hospital?  Short-term commitments are understandable.  Someone does you a favor, you do one in return.  But guilt is a bad foundation for a lifetime relationship, especially when one party feels a lot less guilty than the other.  And remember that you have no patients who depend upon you, no practice employees who you support with salaries, and you know that the ER will continue in in your absence.  So why worry about commitment?  Nobody else does.

Corollary 2:  You can leave

Recognizing that there’s no real covenant between you, a hospital, a contract group, a patient panel, or a community gives you mobility.  If you don’t like your job…and again, it is a job…you can simply leave and no one will be the worse.  You’ll miss some of your colleagues, and they’ll miss you, but that’s why we have Facebook.  So if you’re not happy, leave.  Everyone else leaves bad jobs in search of greener pastures.  Why shouldn’t you?

But if you hate your job, but really like where you live?  That leads us to…

Corollary 3:  Live where you live.  Work where you work.

Emergency Medicine is a Seller’s Market.  There are more jobs than physicians willing to fill them, and that disparity grows when one considers the limited number of residency-trained, board-certified emergency physicians.  As ER volumes grow and the needs for physicians rise, so do the dollars.  Student loan payoffs and signing bonuses routinely top six figures.  It’s a great time to be job searching, right?

The other side of the coin is that many of the best paying jobs are in places you don’t want to be.  I’m sure that by and large, the people of Connecticut (except Geno Auriemma) are fine individuals with a quirky yet endearing affection for nutmeg, but as a native flatlander I have no particular desire to live there.  But for the right money, I can work where the dollars are and still live where I want.  With no connections to a community or commitments to a hospital, commuting is a way of life for many emergency physicians, doing blocks of shifts in distant locales, seeing the country on someone else’s money.  So if you and your family love the beach, but the local ER is a cesspool, go ahead and live at the beach.  Hop a plane to the hinterlands, do your shifts, and go home.  Don’t juggle your commitments; dedicate yourself fully to work and rest, then dedicate yourself fully to family and friends.

This is no just idle chatter.  It’s what I do.  I live in North Florida and commute for my shifts at small physician-friendly hospital back in the Midwest that pays well for the volume of work.  I don’t make as much as I might at the local Trauma Center, but I’m not beat up after every shift, and there’s still plenty of money out there for a very comfortable life.  (The fact is that while we rightfully lament that we’re not paid what we’re worth, we’re never going to starve.  It’s comforting, and freeing, to realize this.)  I’ve got the best of both worlds, and on someone else’s dime.

Corollary 4: Don’t work a moment more than you need

While it’s exciting to be an ER doctor while you’re young and single, it’s hard on relationships.  The glamor of being, and of being with, an ED physician wears off fast, and there’s a lot to be said for having weekends and evenings off where you can commune with the rest of the world, to have those spontaneous moments with your partner and your kids that build connections and create memories.  Real life doesn’t just happen when you’re off shift.  Don’t live to work.  Work to live.

Again, I’m not simply talking to hear my own voice.  My career has given me lots of opportunities to do fun and interesting things.  I’ve flown in helicopters, worked with NASA, served in County and State government.  But working evenings, nights, weekends, and holidays as a younger man, simply caught up in the Wild West Cowboy Thrill of it All (Yeee-haw!), has undoubtedly left me with a skewed sense of priorities in relationships.  The fly-by-the-seat-of-your-pants attitude we have in the ER doesn’t work in the slow and methodical world of building lasting friendship and love where presence is everything.  You need to be there when the sun lights up your face on the weekends, and when relationships begin to fade in the evening shade and die in the dark of night.  There’s a reason many Emergency Physicians talk about their “starter marriages” (plural intentional), and don’t figure it out until they’re at the point where they can cut back on shifts and work mostly days.  It took me twenty years to get there.  Don’t be me.  Make the time.

ER Math:  One night equals two days.  Eight > Twelve.

Remember how you thought it was cool to work only 12 shifts per month and have 18 days off?  That math works in your twenties.  By the time you hit 40, you’ll probably still do okay after a single 12 hour shift in a busy ER, but if you do two or three in a row the following day or two you won’t want to go anywhere or do anything.  And a single 12-hour night shift in your 40’s puts you out of commission for the day before (when you’re trying to nap) and the day after (when you’re tryignt o stay awake).  Twelve night shifts over a month’s time makes you feel like you’re aware of the daylight for about a week, and that’s only if you have a full block of seven days off.  Even at low patient loads, as you age the nights just get harder to do. 

Eight hour shifts have been shown to be more physiologically sound and, to me, are much easier to do.  You can rest without feeling like you’re on a deadline, and you can still have a few hours of the day to yourself.  The trade-off is that you need to work more eight-hour shifts to make the same amount as you would working twelves.  But the trade-off is worth it.  In my most recent ER, the eight hour blocks were called the “Princess Shifts.”  I would happily wear glass slippers if all I had to do was eights.

Don’t kid yourself that you can keep up this work forever.  There’s only so much Provigil to go around.

Work, don’t teach.

I took an academic job right after residency.  I had published a few papers, regularly taught ACLS, and thought I knew things.  Turns out I didn’t, though that didn’t hamper my promotion and tenure.  Yep, you’ve had that Professor, too.  Those who can’t do, teach.

I have come to believe that you are truly lost in trying to prepare anyone for the real world of medical practice unless you’ve been in that same world, in a busy community ER, for at least five to ten years.  While I may have bluffed well, and taken comfort in the fact that patients are surprisingly hard to kill, I’m now convinced that I was so far off base in some of the academic dogma I spouted off that while I may have been an excellent academician, I was not a great emergency physician.  And once I got to the real world, my learning curve was much steeper than it should have been.  So if you want to teach, practice first.  And then when you go into academics, you’ll still have some bucks saved up for nice cars and cruise vacations.

Real emergencies are rare.  Realize why.

You’ve probably already figured this one out.  How many ER patients have you seen without an actual emergency?  About a billion, I’m sure, but it’s likely that nobody ever explained why.  Most doctors in the United States believe that this is a result of the federal mandate that any patient must be seen in the ER for a Medical Screening Exam from a qualified health care professional.  It’s likely true that the mandate allows some people to take advantage of ER services when they can’t get help elsewhere, but that’s not really it.  There are economic drivers at play, one from within the hospital and the other in the mind of the consumer.

On the hospital side, it’s a matter of costs.  Anything with a price can be broken down into fixed and variable costs.  For example, if you decide to drive to the store, the fixed costs are your car payments, annual registration, and insurance.  You assume these costs whether or not you choose to drive on that particular day.  A variable cost is the gas that you use to make that trip, which is an expense you would not otherwise incur.  (You may also hear of opportunity costs, which is the cost of doing one thing instead of another.  For example, if you spend an hour at the store, it costs you an hour of lying on the couch playing Cookie Jam on your iPad.  Or so I’ve heard.)

Hospital ED’s have high fixed costs.  No matter how many patients show up (or if no one does), the hospital is still paying for the bricks and mortar, utilities, nursing and staff wages, technology, office supplies, and the like.  These are fixed costs that never go away.  The more patients you see, the closer the margin between your fixed costs and the concomitant revenue.  (Variable costs in the ER…basically consumables…are a relatively small portion of the total cost).  So even if some of these patients pay little or nothing, the more people you run through the system the smaller the differential between your fixed costs and your income stream.  It’s often in the hospitals best interests to keep the doors open for all.  (You will often hear in your career that the ER is not a Revenue Center, meaning it doesn’t make money for the hospital.  Don’t believe it.  An ER may lose money when you compare the ER charges with reimbursement alone.  But ER’s do make money…lots of it…for the hospital when one considers the tests, admissions, and referrals generated by the ED.)

The second has everything to do with consumer choice.  This choice is not about the “10 Minute Wait Time” signs on the highway.  This is all about convenience.  Let’s say your child has the sniffles.  You can call the pediatrician’s office, be given an appointment in two day’s time, try to take work off during the daytime and hope your employer understands, and fret for two days while enough snot the fill the Hoover Dam eminates from your child’s nose.  If the pediatrician decides that labs or x-rays are needed, maybe there’s another trip to a lab or outpatient facility, and then another wait for the results and perhaps for a prescription as well.  On the other hand, if I can drop into an ER after hours, without taking off work, and get everything done…it’s one-stop shopping, and who wouldn’t take advantage of that?  I probably would.  In the midst of a busy shift I get angry with the way people use the ER, but the inflexibilty of our current outpatient systems to respond to consumer needs has driven them to us.  I don’t like it, but I get it.

Know up front that this is a battle you can’t win.  As Ray Parker Jr. and Raydio noted, “You can’t change that.”

There’s no glory in being a wall.

For years, residents have been described by their peers as walls or sieves.  Walls block admissions and find reasons to send people home, while sieves admit anything.  Your peers, people with whom you’ve worked side-by-side during your first few years, want you to be a wall, and you understandably want to look good in their eyes.  So everyone tries to be a wall.

That doesn’t work in the real world.  Being a wall causes nothing but headaches.  You don’t want to be in the situation where the patient or family pushes for admission and you refuse.  You don’t want to be fighting the wishes of outpatient or specialty family physicians who refer patients to your hospitals.  You don’t want to weigh in on the borderline case, where 51% of patients do well at home and 49% who will go sour.  It is absolutely reasonable to set some parameters for what can or cannot be accomplished during an ER visits (no refill of chronic pain meds, can’t diagnose chronic problems, no elective MRI’s), but being a wall generates complaints and puts both you and the hospital at risk.  If there are issues with the appropriateness of an admission, there are people who are paid to sort that out.  Can you make the argument that being a sieve is inefficient and a poor use of healthcare resources?  Of course you can.  Does being a wall help you personally or professionally?  Nope.  So don’t do it.

It’s a young person’s game.  Have an escape plan.

If I was forced to cut this chapter down to two sentences (ad once an editor gets hold of this, that may be all that’s left), you’ve just read them.  The fact is that you will burn out.  The adrenaline rush of acute care wears out by your early 40’s, beaten into submission by increasing workloads, decreased physical capabilities, the isolation of your work hours, and the burdens that your career choice has placed upon your relationships with friends and family.  You will hate your job, and you will be angry you have to go to work, angry at work, and angry when you come home that you have to go back for your next shift. You will still get excited about some cases of interest and some patients will remain a real joy to care for.  But they will feel like shining stars, light-years apart in the dark cosmic matter of your work life. 

So my best piece of advice to you, even to the point of ignoring everything else I’ve said, is to have an Escape Plan.  It doesn’t matter what it is.  Academics?  A fellowship?  Changing specialites?  Getting into administration, pharacueticals, or medical devices?  See the world as a cruise ship doctor? Medical volunteer work at home or abroad?  Or getting out entirely?  I know emergency physicians who got out to purse a PhD in math, to follow religious callings, to fly right seat in commuter airliners.  One of my mentors wound up working at a liquor store and loved it. 

The most important thing you need to keep in mind is that an MD or DO is a ticket to anything.  You are not trapped by your degree.  A colleague of mine often says physicians should “leverage their degree.”  You’ve survived medical school, residency, and your clinical years.  While you may need some additional training or experience to meet your goals, nobody can say you’re not smart enough, not motivated enough, or don’t have the capacity to learn, grow, and excel.  The MD and DO may not mean anything to those who rely on Dr. Google for their medical care, but it still means something to those who value drive and ability.  Take advantage of this and use your degree to drive your opportunity.

My last caveat:  Never quite give up the ER.  Like it or not, by the time you decide to get out it’s already a part of you, and you’ll feel lost if you never get back in there again.  You’ll miss the sights, the sounds, and even the smells.  So every month, do a few shifts.  ER doesn’t change that much, the ABC’s will always be there, and you’ll keep your credibility as a physician with your friends and colleagues.  It’s a pretty well-paying hobby, and you’ll still have things to talk about at breakfast.  It’ll always be fun to watch the other tables clear out.

Take care of your ER family.  You need them more than you know or want to.  But don’t love them. Love your own family more.

Love and Mercy.  Brian Wilson was right.