Ten Things I Wish I Had Started Doing the Day I Began Practicing Emergency Medicine
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10 things on my ED practice ‘to do’ list

Several years ago, I gave a presentation to the EM residents at Gene Hern’s program at Highland General in Oakland identifying ten things I wish I had started doing the day I began practicing emergency medicine.  Gene asked me to translate this talk into a piece for the CAL/ACEP Lifeline, and I published it there.  In the years since, I am pleased to say that half a dozen physicians have asked me if they could redistribute this list to the docs in their group, or to their EM residents, or in presentations at CME meetings.  Yesterday this happened again, and I thought it was time to reproduce this list in The Fickle Finger, so here it is.  I had only limited success incorporating some of these practices into my routine before I retired, and others I did religiously.  Perhaps you might find them helpful for your practice.

1.  One diagnosis a shift:  try to pick out a patient every shift that sticks out, for whatever reason; and when you have a few minutes, during or immediately after your shift, pick up Harrison or Rosen and read a few paragraphs on the diagnosis and treatment of this patient’s problem.  It doesn’t have to be an unusual problem:  CHF, pancreatitis, retinal detachment, whatever.  We tend to focus on the latest journal articles and newest drugs in our reading, and I found it really helped to review some of the basics, especially in relation to a particular patient.

2.  One staff member a shift:  try to pick one of the members of your ED staff and take a few moments to talk with them about something other than medicine, something of personal interest to them.  Emergency medicine is a team sport, and getting to know your team is part of effective leadership.  This is one I really wish I had done better.

3.  Sit for the history AND for the discharge:  you have all heard that sitting down to take the patient’s history gives the impression that you are really interested in the patient and that you are an active listener.  Likewise, you should try to sit when giving your discharge instructions or talking about admission to the hospital and further treatment.  This is the opportunity to make a final impression about your care, and sitting down to do this once again indicates that you care, and not just happy to be finished with your patient.   Every treatment space in your ED needs a gurney and two chairs (one for you, one for a family member).

4.  Thank the staff at the end of your shift:  this one takes only a couple of minutes but really leaves good feelings in your wake as you leave.  No one in the ED ever gets enough appreciation for their efforts, and if you can be specific around particularly good work, you will reinforce the best in your staff.  Remember, these folks help you earn your living.

5.  Always read the Discharge summary of every patient you admit:  emergency medicine suffers from one particularly vexing problem that makes it difficult to excel as a healer – the lack of feedback and follow up on the care you provide.  How do you get really good at managing septic shock if you rarely get to see the patient the day after admission?  How many surgeons remember to tell you the outcome of the surgery for possible appendicitis?   Ideally, your hospital should arrange to get you access to the discharge summary of every patient you admit, either on paper or electronically.  If not, find a way to make this happen; it is well worth the trouble.

6.  Always thank the paramedic:  a simple idea that I needed to really try harder to do.  Their jobs are at times very difficult, and let’s remember that it’s not hard to triage the paying customers somewhere else.  These folks are part of the team as well, and deserve to be acknowledged for their contributions.

7.  Don’t bitch about it, fix it:  so you have two options – you can gripe about the file cabinet that never has the special forms you need when you look for them, or you can find a way to get all those forms scanned or copied electronically so you can print one out from an indexed computer file whenever you need one.   The most vexing issues in the ED are usually systems or operational issues that typically would be easy to fix if someone in your department took the time to straighten them out.  If you are counting on your medical director or the nurse manager to take care of these issues, they may never get around to it because the list is probably longer than your arm.   Do yourself and everyone else a favor and grease the wheels of your ED on your own initiative.  Be part of the solution.

8.  Bring two cookies for every one you eat:  no one likes a mooch, everyone loves a chocolatier.

9.  Attend every staff meeting you can:  it may not be obvious, but every ED has a mission, and in most cases, several missions;  and it is difficult to be in sync with these missions if you aren’t in the room when your medical director or hospital administrator lays them out for your department.   Why is it important to get on the bus with the rest of the staff in your ED?  Because it only takes one uninformed, disinterested, couldn’t care less team member to steer the bus off the road and into the ditch.  Staff meetings are your opportunity to help chart the course for your practice, learn from your peers, and turn a job into a profession.

10. Call your patients back:  this is the one that added the most to my practice.  I tried to make a follow-up call to about 10 or 12 patients a shift, usually within two or three days, sometimes sooner.  I used this as an opportunity for:  (1) service recovery if the patient did not seem happy when they left;  (2) follow up to enhance my skills and learn what worked best;  (3) enhancing patient satisfaction and the scores that go with this;  and (4) giving my patients an opportunity to ask the questions they forgot to ask at discharge or to seek further advice.  Mostly I did these call-backs because I got a lot of positive reinforcement for the service.  I even called on patients who were admitted, and sometimes I would make a change in treatment if it seemed prudent (and dictate an addendum to the medical record if I did).   There is an art to doing these follow-up calls, and in the near future I might elaborate on the tricks of this trade;  but for now let me say that there are few things in the practice of emergency medicine that brought me as much personal satisfaction as making these calls.

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Ten Things I Wish I Had Started Doing the Day I Began Practicing Emergency Medicine — 9 Comments

  1. about number 10, with our staff we have created a follow up visit , which gives more satisfaction to pacients and diversificates activity to the ER staff.
    11. smile: always, to peers, to patients, to the rest of the team, smile.

  2. 11. Apologise for the wait…every time. If the patient turns around and says: “It’s OK doc, it was only 10 minutes.” Then you say: “I’d prefer if it had only been 5”. Amazing how it makes the rest of the interaction pleasant and smooth.

    12. Keep a logbook of procedures/interesting cases

    I liked all of your 10 items. Especially No.10 but I think in many departments this is going to be difficult due to time constraints and the constant heavy throughput.

    I was interested and maybe misunderstood “I even called on patients who were admitted, and sometimes I would make a change in treatment if it seemed prudent (and dictate an addendum to the medical record if I did).” Does this mean you would alter their treatment whilst on the ward? In consultation with the inpatient team? Or is this on a short-stay unit/ED observation ward?

    • Thanks for the comment, John. Two good suggestions. Sorry if this was confusing, but when I called patients who were admitted, I usually waited a few days before calling them at their home, or I called them in their hospital room if I knew they were still an inpatient, and sometimes I spoke with family members (rarely, and only when it was clear they were deeply ‘in the loop’.). I never attempted to alter treatment plans for patients who had been admitted, or for patients who had seen their own provider subsequent to their ED visit.

  3. 11. Apologise for the wait…every time. If the patient turns around and says: “It’s OK doc, it was only 10 minutes.” Then you say: “I’d prefer if it had only been 5”. Amazing how it makes the rest of the interaction pleasant and smooth.

    12. Keep a logbook of procedures/interesting cases

    I liked all of your 10 items. Especially No.10 but I think in many departments this is going to be difficult due to time constraints and the constant heavy throughput.

    I was interested and maybe misunderstood “I even called on patients who were admitted, and sometimes I would make a change in treatment if it seemed prudent (and dictate an addendum to the medical record if I did).” Does this mean you would alter their treatment whilst on the ward? In consultation with the inpatient team? Or is this on a short-stay unit/ED observation ward?

  4. Pingback: Interesting reads. « Doctor Down Under

  5. This article was a great find. What the author proposes is an exact cultural fit with the tenor of my EM Group. MEP has advocated the same approaches for many years. Can MEP have permission to use the article, recognizing both the author and Fickle Finger, in/on our social media sites and company newsletter?
    You can find MEP at http://www.EmergencyDocs.com.
    Our blog and FaceBook URLs:
    blog: http://www.emergencydocs.com/blog
    http://www.facebook.com/emergencydocs
    Thank you for your consideration. SBoch@EmergencyDocs.com

  6. Pingback: You Can Never Be a Good Emergency Physician Without This... - THE FICKLE FINGER

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