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Now That Youʼre a Real Doctor

2005; Lippincott Williams & Wilkins; Volume: 27; Issue: 10 Linguagem: Inglês

10.1097/00132981-200510000-00025

1552-3624

James R. Roberts,

Healthcare Policy and Management

Learning Objectives: After reading this article, the physician should be able to:Figure Describe the realities of being an attending physician for the first time. Explain the limitations and responsibilities of an attending physician. I send this letter to all new emergency medicine residency graduates who begin to work at my hospital. I wrote it a few years ago, and continually update it. I think it is both an inspiration and a wake-up call, and I thought it might be of interest to even the most seasoned emergency physicians. I think I covered the waterfront, but any suggestions and comments will be appreciated and passed on to other readers. TO: All Emergency Physicians FROM: James Roberts, MD SUBJECT: The roles and responsibilities of emergency physicians and the philosophy of the department About this time of year, here's what you newly minted emergency physicians have done: found the bathroom, seen the knots in your stomachs lessen and the palpitations decrease, made your first huge mistake, saw a case you never heard of before, missed your first intubation in years (in front of the medical students), and ordered a BMW (pending review by your spouse). Now it's time to consider the magnitude of your position of actually being in charge of a real emergency department. Contemplate exactly how to begin to act. The transition is quite difficult for most — hopefully yours will be smooth — but don't get discouraged. This, too, will pass. For your perusal and edification, I have enclosed a letter that I send to all recently hired physicians. It was written a few years ago and was intended for recent graduates, but you should probably refer to it every few years, thinking of it as a sort of recertification. Dear Doctor: I am delighted that you have decided to join or continue with our emergency medicine group. You are one of 22 other residency trained, board certified physicians practicing in a challenging environment that combines resident education and a very busy clinical practice in an academic milieu, and in a faith-based medical system. I am looking forward to the enthusiasm and competence I know you can bring to our organization. I have enclosed a copy of our Missions and Values statement, and I urge you to read it carefully and ponder its significance to you and our patients. This letter describes the philosophy of the department (that is, my perspective). I don't want to sound like your father or be too maudlin, corny, or holier-than-thou, but bear with me; I've been around for a while. How to Survive as a New Attending Any philosophy is much easier said than done, and the following is no exception. A lot of this is what I personally strive for, although I have not always been successful. I personally screw up about three times a week; I'm just better at hiding it than you are. That comes with experience. Everyone must evaluate his particular approach, skills, interests, and capabilities, but I would like to set the tone for the department with this letter. Like you, I struggle with the ideal and philosophical versus the real world with its serious limitations of resources and time. These mechanical limitations are always coupled with the omnipresent human limitations and the ubiquitous stresses of treating the sick, injured, and downtrodden, and occasionally the noncompliant, drugged, drunk, demanding, and overtly hostile patients. Words of Wisdom Charting, documentation, and billing pay your salary. It's prudent, however, to keep in mind that the 84-year-old with chest pain for the 99th time, the prisoner beaten by a cop's nightstick (maybe those two dudes actually did jump him for no reason), and the mother of six (two infants with her) with lower abdominal pain probably does not want to be in the ED at 3 a.m. any more than you do. Few will ever believe the scenarios that you eventually come to view as everyday life in the ED. Most of society could not begin to appreciate or handle what you have chosen to do, and like most of the unpleasantness in the world, they opt to ignore or disbelieve most of it. Your spouse and mother will never understand your day at the office. The ED will always be at the end of the social, medical, and unsolvable problem funnel, so a lot of grief and even more frustration come with the territory. You are expected to handle problems that no one else could ever solve, some that many would not even try to decipher. I laud your efforts and enthusiasm. Welcome to reality; sometimes it sucks. Words of Wisdom You are expected to be a bedside teacher, compassionate and humanistic individual, competent businessperson, quintessential politician, and a role model clinician, all at the same time. We are all at Mercy partly because of resident education. You will be expected to be a bedside teacher, compassionate and humanistic individual, competent businessperson, quintessential politician, and a role model clinician, all at the same time. I expect that you will always practice emergency medicine at the level at which you have been trained, but usually you will be called upon to exceed that level. There is no training to equip you totally for this job. You are no longer the resident; you are now the mentor. The buck stops with you now. You have the final responsibility for your patients' lives and well being; many will have no other advocate or support system, and that is indeed an awesome and often stressful responsibility. You are the team leader, and I expect you always to portray a positive attitude and a professional demeanor, and to set the tone for the entire staff. Any negative attitudes toward the hospital, the staff, or especially the patients are quickly transmitted to and adopted by everyone. Medicine is a tough job, always stressful, and it may be difficult at times to remain focused in the heat of the moment. It is your responsibility, however, to predict and minimize potential problems with families, attendings, consultants, nurses, the lab and x-ray, and paramedics. In essence, you are the Mercy Hospital that is on display to the public. An Imperfect System You are often treating the disadvantaged, poor, helpless, hopeless, and hapless in a war zone atmosphere. If you want a quiet ED with all the bells and whistles and a cash-paying clientele in three-piece suits, you picked the wrong hospital and probably the wrong profession. The system is very imperfect. It always has been and always will be. Use your ingenuity to provide the best care for your patients with the always limited resources. You will never have enough time, personnel, equipment, or backup to make this job an easy one. If you want an easy job, go sell shoes at the mall. “What size? What color? How do they feel? Which credit card?” and you're done. You will never get complete agreement on any issue in medicine or with any political or logistical problem. As a general guideline, always put the patient's well being, comfort, and his family's expectations first and foremost in your plans. As a last resort, you always can keep the patient in the ED until the sun comes up or you can get assistance or resolution. Above all, always, always, always be nice. (That's clearly easier said than done.) Be nice to patients and their families but also to the housekeeper, security guard, cafeteria worker, and x-ray tech. Talk to your patients, talk to them again, and always, always, always talk to the family. Try to sit down whenever possible; it shows the patient you are giving him your time and interest. Words of Wisdom Don't criticize another physician or hospital publicly. Many patients, residents, and attendings need a lesson in manners and compassion. You probably can't teach them much at this stage, but you can always be nice to everyone, even if it hurts. That 300-pound demented nursing home patient with bedsores and a feeding tube is somebody's mother, and maybe she was the best third grade teacher Philadelphia ever had, and just maybe her daughter is on the city council or on the hospital's board of directors. Do not argue with patients over non-issues, such as a few Percocet, an x-ray or blood test, or even admission to the hospital if it's a close call. Resist the temptation to be correct or vindicated. Resist the temptation to criticize another physician or hospital publicly. You will develop a firm grasp of hindsight, but you are in the fishbowl every day; no need to convey that feeling back to a colleague. Take the higher road. Emergency physicians generally respond to a higher calling anyway. Let that overpaid and underworked prima donna surgeon/internist/board member look like a jerk to all who witness the barrage against a hardworking clinician who has to make the really hard decisions. Your impressions of another physician or administrator quickly become the impressions of the patients, residents, and nurses. Do not get into public shouting matches with patients or the staff. Do not argue in public or in front of patients or with residents or attendings from other departments. Try to keep cool under seemingly impossible circumstances. If you see a problem with an attending, nurse, consultant, or technician, write me a note with documentation. You can personally step in where reasonable, but don't try to navigate high-stakes political waters alone; you may often make it worse. Remember that there are always two sides to every story. Hubris should be eschewed at all times. You're simply not that good, smart, or accomplished to be inflexible or pious with a colleague or a patient. Arrogance gets you into trouble more quickly than incompetence. By the way, I like to be aware of your potential problems before I hear about them from someone else. Remember Being a Student Residents and medical students can be fragile and insecure. Remember that first time you presented to the erudite senior professor instead of a resident who had only a few more years on you? You can give them confidence in their ability and career choice or totally shatter their self-esteem with a single encounter in the middle of the ED. While house staff and students may seem totally in control on the outside, on the inside they often are scared stiff. It's a fine art to learn how to critique without criticizing, to instruct without insulting, and to evaluate without enfeebling. Teach them how to be good doctors, not how to ridicule a trainee when they are in your position. Students are expected to surpass their teachers in many talents, and if they eventually do not, maybe you weren't such a good teacher after all. There is no shame in calling a consultant for a medical problem or situation that is going poorly or if you are in over your head. Anesthesia and pediatrics probably possess some talents that you do not. If the husband of a woman with her 200th migraine demands a CT scan or neurology consult, give it a lot of thought before taking a contrary stand. You cannot practice medicine under the constant fear of malpractice, but remember that many malpractice cases are filed because of personality clashes, a physician's insensitive comment or action, failure to communicate, or merely perceptions of physician negligence or inaction by the family. Again, arrogance is worse than incompetence. The family can accept that their loved one may die, but the doctor has to care, has to try, and has to communicate these feelings. Be especially nice to old people; you will be one in a heartbeat. That old guy from the nursing home may not be able to remember his doctor's name or what that 12-inch scar on his abdomen was from, but he just might be able to remember fighting for his country in the Korean War. Be nice to the homeless. You are lucky to have a home and a regular paycheck. Remember that HIV is a death sentence, and these patients don't need your attitude about their lifestyle superimposed on their illness. That sickle cell patient, alcoholic, or crack addict would probably like to be drug-free if there were a better life in the offing for them. Having a baby at 13 can be a normal lifestyle when your mother had you at 12. The next time you make a comment about the teenager with herpes or the kid who took an overdose after being dumped by his girlfriend, remember that your son or daughter may not be immune to life's temptations and stresses either. Reader Feedback: Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Literature references are appreciated. Pertinent responses will be published in a future issue. Please send comments to [email protected]. Dr. Roberts requests feedback on this month's column, especially personal experiences with successes, failures, and technique. Most physicians and family members shy away from the mentally ill, and it's very, very hard to be their doctor. Usually they can't find a good one. Nobody wants to be neurotic, bipolar, or psychotic; just be thankful that your serotonin/dopamine levels are under the bell-shaped curve most of the time. If you won't help these segments of society that can't help themselves, who will? As I said, few will even try. Medicine as a Service Industry Medicine is a proud and noble profession, but it is, actually, just another service industry. Get used to hearing, “When are you going to wait on me?” Hopefully you do not feel like a glorified server, but the patient is a customer similar to the guy in front of you at McDonald's. He wants his hamburger cooked to order, and “special orders don't upset us.” Your customers, however, wait a heck of a lot longer to be served, and they have the bellyache before they eat the greasy meal. Words of Wisdom Always, always, always be nice to the patients and their families but also to the housekeeper, security guard, and x-ray tech. If your patient wasn't happy with your first plan or diagnosis, reconsider it, work out something else, get a consultant. Remember when you had to take your car back to the dealer for the same problem three times. Everyone feels entitled to the best health care; some feel more entitled than others. No one will ever know how hard you work, and most patients think you make half a million dollars to start, and I find a patient's entitled attitude the hardest issue to ignore. Get over it, or it will drive you nuts. In addition to all of this, there is the harsh reality of running a business. Charting, documentation, and billing issues are part of the annoying routine that pays your salary. Charting can be you best friend or worst enemy, especially in any malpractice case. Don't write anything on the chart that you would not want to see in the Philadelphia Inquirer or would be embarrassed to read to your mother or a colleague. Medicare and the like also commonly review your records. All those former cold war CIA agents with a lot of time on their hands are now looking for Medicare fraud. At some point, you will be sued, almost guaranteed, by one of the six zillion lawyers on TV at 2 a.m. in Philadelphia. It's just one cost of doing business. This can be minimized if you pay homage to the paperwork! If you are just beginning with us, I will give you a crash course on charting, your role as a supervising physician in the eyes of the accountants, and some potential ways to stay out of or limit your time in the courtroom. A few other nuts and bolts issues. Being a doctor can be viewed as a privilege or an entitlement; choose the former. You are well compensated for your time, no one gets paid what he is worth, but we do OK in the grand scheme of things. Although I am always more than willing to discuss issues and problems, I would appreciate it if you would not whine or complain. Nobody likes a high-maintenance employee, especially a professional one who should generally be self-starting, innovative, and self-sufficient. To paraphrase John Kennedy: “Ask not what your hospital can do for you, ask what you can do for your hospital.” I can't run your social, personal, or financial life for you; life is tough in the big city. I can name 20 people who came to me last week with problems, but offhand I cannot name a single one who came to me with a solution. Note that the schedule is sacred. Don't miss a shift, and learn how to show up on time. No one likes a replacement that is always 10 minutes late. We know who you are. That dead battery or the stuck-behind-a-school-bus excuse only works a few times. And, of course, there may be a lot of days where you won't get off duty on time. And by the way, keep your love life (and lover) out of the ED. On the other hand, there is more to life than medicine. You can always make up a switched shift, but you can't make up a soccer game, anniversary, birthday, or family vacation with your 8-year-old. Remember that you might need a shift off some day, so be ready to help a colleague who asks for a schedule switch. Words of Wisdom Watch out for plaintiffs' malpractice attorneys. If you sell your soul to the plaintiff, your colleagues will recognize you for what you have become. Medical World by the Tail In my opinion, we currently have the medical world by the tail. We show up for work, work hard, then go home: no beepers, no calls for orders, no insurance forms to fill out, and no bills to collect. Heck, we get paid even when the hospital does not collect a cent. You don't have to interview clerks, fill the nursing schedule, or even have to find a replacement for your vacation time. You clearly work hard for your paycheck, but any general practitioner or pediatrician in the city would take your job, and salary, in a nanosecond. Let's hope Camelot lasts until retirement. The way things are headed, though, I suspect today is the “good old day” of tomorrow. Next time you think you are underpaid and overworked, consider the pediatrician or GP who works 80 hours a week and makes less than you do. And never discuss your salary with a hospitalist! Finally, if you plan to give medical expert testimony, start a side business, work out a deal as a consultant, speak for a drug company, or do any professional activity that will reflect on Mercy, I suggest you speak with me beforehand to avoid common pitfalls. I never turned down an honest scam to make an honest buck, but it's a very seductive world out there, and your reputation and the hospital's good name can sink like a stone. I would particularly warn you to watch out for plaintiffs' malpractice attorneys. They all sound so nice and righteous on the phone, and money is never an object. I don't have a problem with your supporting a wronged or injured patient; there are bad doctors out there and some patients rightfully need to be compensated. But you can build a home in Hawaii on what you can make by selling your soul to the plaintiff, and all of your colleagues will recognize you for what you have become. Finally, be careful with alcohol and your ready access to Vicodin and Percocet. Enough said about that, but addiction can ruin a lot of lives in a very short time. Hopefully, this will help you adjust to your new position, and maybe you won't make many of the same mistakes I have. Maybe selling shoes is not such a bad idea after all.