Advice for new EM graduates

From the council of emergency medicine residency directors

http://www.cordem.org/i4a/pages/index.cfm?pageid=3634

Advice for Graduates

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Preparing to Practice: Advice For New Graduates and Young Physicians: 
Avoiding the Pitfalls

Compiled by Stephen R. Hayden, MD
Professor of Clinical Emergency Medicine
Associate Dean for Graduate Medical Education UC San Diego

Acknowledgment: Thank you to all the members of the Council of Residency Directors (CORD) in
Emergency Medicine for your sage advice and invaluable contributions to this work!

Outside Activities/Personal: Pitfall is not taking care of yourself; physically, mentally, and spiritually…

• “Tell them to rediscover their passion outside medicine so that they can rely on it to de-stress and add dimension to their life. For me it is ballet, but many others do sports, music, church groups, community organizations, art, etc. The nice thing is that they get a circle of non-medical friends to add perspective to their lives. For most people, all these interests were suppressed during clinical training.”
• Make time for yourself (separate from time for your family)...get back into that exercise routine that fell by the wayside during residency (or sport or instrument they used to play)
• Find a balance between work and play, don’t forget to take care of yourself
• Taking a job that they end up loathing for whatever reason, and then not having the courage to leave and find another one

Finances: Pitfall is getting in over your head

• Start saving up during residency for the first year out.  “There are a LOT of expenses no one told me about.  Moving, security deposits, first and last month's rent, boards fee (both written and oral - plus travel and lodging to Chicago!), cost of licensure.  It adds up to several thousand dollars.”
• Don't spend more than you earn.  Spending quickly rises to match income.  Don’t live beyond your means now that you are getting a real paycheck.  Don’t buy a house too soon or buy a very modest one initially.  Owning a home can get you in over your head faster that you can imagine. Don’t buy a $60K BMW right away!
• “Do not underfund your savings plan, do not overpay for a car.  I see too many recently graduated residents buy a big ticket item as soon as they become attendings (usually some ridiculously expensive car) but not put money into savings.  They need to max out their 401k/403b from day one.  If they never see the money going into their savings plan, they never feel the hurt.”
• Realize that you are immediately in a new tax bracket and plan accordingly
• Pay off some debt, live like a resident financially for a while which allows for saving money so you can travel, change jobs if needed, etc.
• Start saving for retirement as early as possible, and start college funds for your kids the minute they are born
• Continue short term disability plans from residency if possible as they are often fairly inexpensive and not all groups offer short term disability (some policies allow this and this is particularly important for females who may get pregnant). Some companies offer a guaranteed issue disability policy to residency graduates; take advantage of it.
• Many residents do not understand their contracts or sign ones that may get them into trouble, i.e., agreeing to restrictive covenants, etc.  Don’t feel like you won’t get the job if you don’t agree to all the provisions; in the end almost everything is negotiable.  Look to your specialty societies if you are not sure or have questions.

You are not Alone: Pitfall is being afraid to ask questions or ask for help

• You can always call 'home'.  If you are out moonlighting or on your own and just want to bounce something off one of your colleagues from where you trained, you can always call.  Someone from your department is on 24/7.  Sometimes it just helps to think out loud and with another brain that knows your brain. Stay in communication with the mothership!
• Never lose your humility or be too afraid / too proud to ask for help.  Just because you've graduated, doesn’t mean you know it all / can do it all. Medicine is the most humbling of professions; if you don't know the answer, ask!
• If you're not sure about a patient case, ask your colleague who's working with you.  It's not a sign of weakness.  Your colleague has one thing that a new grad does not - experience.
• First 5 years out of residency is a steep learning curve; you’ll see stuff you’ve never seen before, you may do procedures you’ve never done before, better to admit you’re not sure than make something up.

Compassionate Care: Pitfall is forgetting why you got into medicine in the first place

• “Take the time to make a true connection with a minimum of ONE of your patients per day or shift.  Take the extra time and make the extra effort to create a connection and find out something about them as a person.  it helps you keep your humanism and remember why you got into this business - to help people.
• Graduates must never lose their compassion; if they see themselves moving towards indifference, do something about it; compassion is the most important quality associated with a long and happy career.  And the obvious corollary… never forget your patient is an actual person and not a scientific problem.
• In the first few years of practice most graduates end up making an important, but unconscious, choice between compassion and indifference toward their patients.  Young physicians who seem jaded and annoyed by their patients (or “hits”) frequently become bitter as the years go by.   Others who really take the time to listen and care for their patients seem to become more satisfied as they go on.
• Consistently regarding your next patient as an opportunity to care, rather than a burden or an obstacle to getting home, is the best guarantee for long-term success.
• Be nice to as many people as possible; “Kindness is contagious”.

Burn Out: Pitfall is succumbing to the pressures of clinical practice and burning out

• “I see a certain curve in young physicians… nervous/uncertain at first, then they gain confidence and after a few years become a bit overconfident, until something bad happens; for the high performers particularly, as they expect more and more from themselves, often forgetting to maintain their private lives, there is a tendency to burn out in years 3-5 (loss of compassion/empathy, de-humanizing patients, judgmental, short tempered, hard on their colleagues, etc.).  This is a repetitive pattern and over the years I have come to look for it.  Noted early it can be readily reversed, but if allowed to progress it can become a crippling issue.  So I warn people about this and I have been told it helps.”
• “One of the things I wish someone told me was to watch the amount of overtime I take on. New grads are seeing real money/pay checks for the first time. OT is real alluring because new grads think they need all this money to pay off bills and other debts they have accumulated. However, if they do too much OT they get burnt and cranky and they can't enjoy their new jobs/positions.
• Remember what you enjoyed as a resident.

Treat Others Well: Pitfall is now that you are a real doctor thinking you are above your coworkers

• Listen to your nurses and staff.  They will save your ass more than you know!  Scorn the nurses... look for a new job!
• Not being a team player (you are the new guy that means watching more than talking).
• Telling all the 'old' guys how to do it!
• Get to know other medical staff and review a list of your consultants with the current staff to find out who is really helpful/unhelpful, who has a personality disorder, who you can call in a pinch even if they’re technically not on call, etc.  You need to feel you are part of the larger physician team of the hospital - even if you don’t like all of them. 
• Bring food for everyone to your department/office for at least the first month (or longer).
• Ask the nurses/techs what you can do to help out and clean up after yourself without being asked (I promise the return is greater than the effort!)
• Not treating other physicians as if they were members of your own family, especially when one of them becomes ill.
• Be the "yes" person.  If you can do it, and there is no reason to say no, then say "yes".  Be the dependable person others can count on. What goes around, comes around.
• Your character is revealed by the manner in which you treat those least important to you…
• “As my 9 year old daughter tells me often - Smile.”  It's contagious.  :) 

Clinical Practice: Pitfall is not doing what you know is right

• Do not make a “fence decision” that you will lose sleep over. If you are second guessing yourself while the patient is still in the ED, office, or on your service, you WILL wake up in a sweat at 3 in the morning questioning why you did what you did (or didn’t!)
• There are very few absolutes in medicine. Practice varies from hospital to hospital, region to region and by provider so learn the local standards. Be cognizant of this and be flexible. Don't sacrifice your training and principles but decide which battles to fight.
• Forgetting to use their history and physical exam skills to diagnose their patients, not the CT scanner.
• Be prepared for change: clinical practice will change and you must keep up with current medical knowledge.  Develop a regular reading plan. 
• Becoming complacent in patient care; at graduation they are proficient but it will take many thousands of patients and many years to become a master.  Keep working at it; like the flight community says – complacency kills!
• You will have to reinvent yourself – maybe several times, be open to it (protect yourself from tunnel vision).
• Document scrupulously and honestly.  Always do the right thing, DESPITE: Managed care, cost-effectiveness and administrative pressures.
• You are a professional, maintain professional standards at all times and in all situations.  Whether you like it or not everyone looks up to you.  Beware of social media – don’t post ANYTHING that is even remotely socially questionable, invariably your boss will end up seeing it and it could cost you your job.
• Ask yourself; how would your mother feel about the way you conducted yourself if she read it in the newspaper?

Academics: Pitfall is not learning the art of saying both yes and no

• Not going that extra mile if you are in academics because you are just starting out, e.g. reviewing, research, taking on the med student rotation, etc. 
• Learning to say no is an art form; however, don’t say no too often early in your career because the offers may stop coming.  Rather learn to say yes to the right things and seek out something you can become passionate about and can take you places. That one random "yes" could lead to a niche you never would have thought possible.  Create a niche for yourself.
• Talk to your chair early, ask for help getting involved in important departmental activities but at the same time limiting them so you can focus on becoming very comfortable with your new role as a clinical attending physician.
• “We give people titles in academics too quickly. I think I ruined one of my best grads by making him an APD right out of residency. Now he’s stuck in a wrong path and not very successful. My new rule, no promotions for 2 years… awards, thanks, gifts, sure.  No titles.”

Professional Development: Pitfall is not placing a high enough priority on it

• Forgetting that the first day after graduation is the beginning of a process in which you actually learn how to practice your specialty, not the end.
• Get involved with hospital committees, county and state medical societies, etc. Get involved at a local/regional and national level.
• Specifically getting on your departmental or hospital QA committee - it's a good way to learn your clinical  processes and what the standard of care is for your institution.  Also, always best to learn from others 'mistakes'.
• Consider a leadership development program.
• Find good mentors and continue mentor relationships from residency.
• Give back to your specialty.

Passing Boards: Pitfall is not allowing enough time to prepare for them

• Do not slack in studying - You are not really done until you pass your boards.
• Seriously review for your board examination regardless of your last In-Service score. Every PD can relate a story about an excellent, competent resident with a great final In-Service Exam score that then flunked the written or oral certification examination!

Remember The Six C’s

Compassion

Remember why we do this in the first place
Be careful to avoid callousness, hardness & burn-out (“Easy to be hard…”)

Compulsiveness

Be compulsive in your:
Charting
Record completion
Filling out paperwork
Patient care
Life-long learning
Showing up on time

Caution (Conservatism)

“Be neither the first, nor the last, to adopt anything new”
Most new, pushed drugs are not necessary (Vioxx, Celebrex, Ketek)
“First, do no harm”

Conflict resolution

There will be lots of potential fights, with:
patients, privates, partners, boss, staff, RN’s, etc.
Learn to gracefully & diplomatically avoid or resolve real and potential conflicts
Prevent escalation
It usually isn’t really worth it, after all
Being right isn’t enough - to get ahead, you’ve got to get along
You don’t want to be the one that everyone thinks is “difficult to deal with”

Committees

Despite the hassle, be involved professionally at the:
Departmental level
Hospital level
Community level
Professional organizational level
The investment in time pays off multiple ways
But wait until after your boards!

Communication

In your documentation
With your patients and families
Always spend an extra minute or two
With ED staff
Learn their names
Show respect for them 

Rosen’s Troll Theory:

Trolls are everywhere; you know who they are and you have interacted with them.  They are in every clinical practice, office, and organization and their sole purpose is to frustrate  you and prevent you from getting what you want to get done.  In order to be successful you need to beat the trolls at their own game and there is a scoring system:

• If you get the troll to do what you want, and don’t lose your temper you win; you get 1 point
• If you get the troll to do what you want but lose your temper in the process; call it a draw
• If you can’t get the troll to do what you want, but you don’t lose your temper the troll gets 1 point
• If you can’t get the troll to do what you want, and you lose your temper the troll wins; they get 2 points!

As you can see the world favors trolls, and so the essence of career success and avoiding these pitfalls, is to get the trolls of the world to do what you want them to without losing your temper or better yet to make them think it was their idea in the first place. In this manner you will avoid being "betrolled".