EMERGENCY MEDICINE - A Practical Perspective
Joseph G. Mueller, M.D.
Woodrow Wilson said, "The President is at liberty, both in law and conscience, to be as big a man as he can. His capacity will set the limit." I hold the same is true for Physicians. The opportunity for greatness, to be as big a man or woman as we can, is inherent in our profession. The exact nature of this greatness will be unique for each individual. One may attain it through research, for example, and another in private practice. The common thread, however, will be the individual physician's ability to maintain both the proper focus and perspective throughout his career, allowing him to strive continually for excellence.
Emergency Medicine is a wonderful and unique medical specialty in which the opportunity to step up to the plate and realize one's capacity presents itself on a daily basis. Issues unique to the specialty, and the day-to-day chaos and intensity of the practice, can undermine the Emergency Physician's purpose; however, these difficulties can also provide one with the chance to test one's ability and character.
Thus, while the difficulties inherent in Emergency Medicine can be distracting, they also provide fertile soil for a meaningful and productive career. One's capacity will set the limit!These essays are presented in order to provide guidance and perspective for the student or resident entering the complex world of Emergency Medicine. They are based on my readings, experience, and observations over a career in both community-based and academic Emergency Medicine. Hopefully insight will be gained, creating a strong foundation from which one may then rise to the occasion. For while the challenges will be unlimited, so too may be your capacity.
During the 1950's, Emergency Medicine as we know it today did not exist. Residents and interns staffed the ER at teaching hospitals with little direct attending supervision. In the community, staff physicians had a rotating call for ER coverage. In other words, part of the agreement when given staff membership at a hospital was that the physician would cover the ER once or twice a month. In these community hospitals the ER tended to be small and see few patients since most patients could contact their accessible private physician when a problem arose. Often instead of remaining in the ER for the duration of the shift, the covering physician would be called in when a patient arrived. If the covering physician had training and experience related to the patient's problem, it would be handled adroitly; however, often it was necessary to call an on-call specialist to manage the case. Thus, for example, a Pediatrician covering the ER easily dealt with pediatric patients but called early and often when faced with Orthopedic or Obstetric cases. The Orthopedist and Obstetrician would likewise ask the Pediatrician to take care of children in the ER. As a result there was a general attitude that the doctor in the ER did not know what he or she was doing, and often this was accurate. (Today this legacy can still rear its ugly head in the form of misguided prejudice and criticism of Emergency Physicians by those who do not understand that much has changed since those early days.)
By the 1960's ER visits were increasing due to population growth, busier and less available private practitioners, and changing patient expectations (the desire for immediate and 24-hour access to care). Hospital administrators began hiring physicians to work in the ER. Busy and established private practitioners were glad to give up the unpleasant task. Moonlighting residents and young practitioners looking to make ends meet were eager to pick up shifts and some extra money. Some physicians realized they preferred the practice, money and lifestyle of working in the ER over their initial career plans and began working full-time in the ER. Thus the first Emergency Physicians tended to be the misfits of medicine: physicians who left private practice and residency for a variety of reasons. These misfits were also cowboys. They chose to practice in what was considered an undesirable and un-chartered field of medicine; they tended to move around the country from ER to ER, stay out of hospital politics, and with no accepted practice guidelines shot from the hip practicing as they saw fit. From this motley group a specialty developed.
In Alexandria, Virginia physicians organized themselves as the first group of emergency specialists dedicated solely to providing 24-hour coverage in the ER. At the same time the American College of Emergency Physicians (ACEP), the Society of Teachers of Emergency Medicine (STEM), and the University Association for Emergency Medicine (UAEM) formed and began defining a core body of knowledge, establishing training guidelines, and developing an evaluation process for physicians practicing Emergency Medicine. The latter 2 organizations subsequently merged to form the Society for Academic Emergency Medicine (SAEM). As a result of knowledge gained from the Viet Nam experience, trauma care was revolutionized by a joint effort between academic Surgeons and Emergency Physicians. Today's trauma approach and the Emergency Medical System is a direct result of this collaboration. With the present status quo of Emergency Medicine as an accepted practice and specialty it is difficult to realize how revolutionary the founding fathers were. It was their vision and efforts, however, that transformed a hodge-podge of inconsistency, afterthought, and disrespect into a respected specialty and the front door of today's hospital.
In 1970 the first Emergency Medicine residency was developed at the University of Cincinnati. In 1975 the American Medical Association (AMA) approved a formal section on Emergency Medicine. In 1979 the AMA Council on Medical Education and the American Board of Medical Specialties (ABMS) approved Emergency Medicine as the twenty-third recognized specialty through approval of the American Board of Emergency Medicine (ABEM) as a conjoint board with input and oversight from other specialty boards. Finally in 1989 ABMS approved ABEM establishing it as a member of ABMS and a full primary board.
In 1979 when ABEM became an ABMS board its directors set up a practice track that would be open for eight years, allowing those physicians with a certain amount of clinical experience to sit for boards without completing an Emergency Medicine residency. It allowed the founders and original teachers of the specialty as well as physicians already practicing to become Board Certified. Most medical specialties have practice tracks early in their history while their training programs are developing. Thus many of the early Emergency Physicians became board certified by "grandfathering in" on the practice track. In 1980 the first ABEM examination was given and as scheduled in 1988 the practice track was closed. One still sees physicians not trained in Emergency Medicine working in ERs; however, the only way to become board certified presently is by completing residency training in Emergency Medicine and then passing ABEM boards. Today ABEM co-sponsors subspecialties in Toxicology, Sports Medicine, Pediatric Emergency Medicine, and Hyperbaric and Undersea Medicine. There is a parallel Osteopathic Emergency Medicine track.
By 2005 there were 132 programs in the United States (and over 21,000 diplomates certified by ABEM). Emergency Medicine has become one of the most sought after specialties. It attracts the upper crust of medical school classes with increasing regularity, and true to its cowboy heritage also continues to attract individuals with strong and independent personalities. The cowboy mentality persists, but as the Emergency Department is now an economic, political, and strategic force in medicine, Emergency Physicians are increasingly involved. In other words, Emergency Medicine has become mainstream.
Emergency Medicine came of age during a time of drastic and rapid change in medicine and society. As a result it is a truly modern specialty, attuned to such concerns as malpractice, reimbursement, and health care reform. These issues, while problematic, are simply part of our training and practice rather than new and foreign forces thrust upon old and established ways. Just as the adept Emergency Physician reacts and adjusts to complicated situations in the ED, so too the specialty has reacted and adjusted to the complicated and ever-changing world.
What is it that distinguishes Emergency Medicine from the other specialties? Some would suggest that the Emergency Physician is a jack-of-all-trades. Others might add that we are masters-of-none. The truth is neither.
The jack-of-all-trades image stems from the fact that Emergency Physicians care for patients of every type; therefore, they must have knowledge and ability in all areas of medicine. This broad-based nature of Emergency Medicine is both rewarding and demanding, and makes Emergency Medicine different and fun, but the field is not all- encompassing. It is true that with each case, one is held to a standard specific to the specialty that involves the patient's problem. Thus, when caring for a patient with an eye problem, the Emergency Physician must manage the case in a manner that is satisfactory to the Ophthalmologist. Likewise, the patient suffering an acute myocardial infarction must receive care appropriate from the Cardiologist's perspective. One might surmise, therefore, that to practice Emergency Medicine it is necessary to know everything, or to be a "jack of all trades". The reality is that, while the Emergency Physician must be adept in all areas, the expertise is more focused on the acute management and indications for specialist involvement. For example, all fractures require proper neuro-vascular evaluation, pain control, reduction, and immobilization. Some need to be seen by the Orthopedic Surgeon immediately and others can wait. The immediate management is the Emergency Physician's responsibility, while the definitive treatment (urgent or routine) may be handled by the Orthopedic Surgeon. The Emergency Physician must know not only how to handle the case in the Emergency Department, but also whether the specialist is needed urgently, routinely for follow up, or not at all. Mistakes along these lines can be costly. Also, with busy office and surgery schedules specialists cannot afford to be called in unnecessarily (as they were in the pre-Emergency Medicine days), and rely on adept Emergency Physicians to make appropriate decisions regarding the indications and timing of specialist consultation. The Emergency Physician must therefore be knowledgeable in all areas of medicine, understand other physicians' practices, and be able to manage most outpatient cases without consultation. A jack of all trades? Not really. Instead, a specialist with broadly based yet uniquely focused knowledge and abilities.
On the other hand, Emergency Physicians ultimately refer all patients and the "master of none" retort sometimes is added. This also is inaccurate. Certainly the Cardiologist knows more Cardiology, the Obstetrician more Obstetrics, and the General Surgeon more Surgery than the Emergency Physician. On the other hand, the Emergency Physician is best suited to collectively handle patients from these and the other fields as they present unpredictably and with uncertain diagnoses simultaneously. Also there are critical actions early in the course of all cases that must be readily handled. For example, while there are likely no Emergency Physicians that do not quietly sigh in grateful relief when the Cardiologist arrives to care for their patients experiencing acute myocardial infarctions (no specialist being more able), the Cardiologist arrives on the scene after much has happened in a short period of time. Intravenous access, various treatments (often including resuscitative efforts), and a tentative diagnosis and plan have been rapidly obtained in the Emergency Department. It is unlikely that a Cardiologist would manage the heart attack patient with the same alacrity as the patient staggers into the room stating, "I don't feel very good." Such a patient is critically ill, yet has no diagnosis, is without IV access, and may be fully clothed or uncooperative. There is little information, yet assessment, stabilization, treatment and disposition must occur rapidly or the patient dies. No one handles these initial action-packed minutes better than a good Emergency Physician. Similarly the Obstetrician must provide the definitive care for a patient with a ruptured ectopic pregnancy, but it is the Emergency Physician who arrives at that conclusion quickly, initiates the resuscitation, and promptly arranges for the Obstetrician to come in. This may seem straightforward, but with the chaos and uncertainty of the Emergency Department (underscoring the importance of running a "tight ship") it can be quite tricky. The Emergency Physician must be as a running back, shooting for the opening with boldness, but able to change direction adroitly as the situation does too. Critical actions may seem obviously simple to the outsider and after the fact; however, like playing centerfield, it looks easy until you try it yourself!
Surgeons provide the definitive treatment for most emergent etiologies of abdominal pain; therefore, some might again apply the "master of none" label on Emergency Physicians. Often it seems that the General Surgeons have bragging rights as abdominal pain experts. I suggest that Emergency Physicians are in fact abdominal pain experts also, as we see more patients with abdominal pain than any one else. Emergency Physicians must evaluate, treat, and discharge many patients before calling in the Surgeon. Patients, most of whom have similar symptoms, must be sifted through to determine which ones are at risk. The Surgeon becomes involved when, by definition, the suspicion for significant pathology has been raised making the diagnostic dilemma a bit more straightforward. The trick in the Emergency Department is "knowing when to hold ‘ em, knowing when to fold." Again this subtle responsibility may seem simple, and is certainly not as glamorous as actually removing an appendix, but it still is a complex and important task that Emergency Physicians handle better than anyone else. Similar claims can be made regarding our expertise with trauma, airway, sedation, pain control, toxicology, psychiatry, public health, etc.
A broad-based and practical knowledge combined with an adept and elaborate ability in sizing up situations quickly, sorting out the seriously ill, and intervening with critical actions is what defines Emergency Physicians. Jack of all trades? Master of none? Not! A unique and demanding specialty? You bet!
Some people view Emergency Physicians' schedules and lifestyles as easy. Often, one hears comments such as, "ER docs have great hours." Interestingly it is rarely Emergency Physicians themselves expressing this sentiment. The myth and outward appearance of benign schedules can lure the unknowing into the specialty and prompt jealousy and resentment from the other specialists. The reality is that the life of an Emergency Physician, like all doctors, is far from easy.
When classifying hours, it is safe to assume that most people consider desirable the day shift Monday thru Friday. It is also safe to assume, therefore, that most would consider undesirable all other shifts (i.e.: evenings, nights, weekends, holidays). As there are only five "great" shifts a week, the majority of hours an Emergency Physician works are actually fairly crummy. The Great Hours Myth stems from wrongly equating predictable and less total hours with great hours, as well as an under-appreciation of what transpires during those hours.
Predictability of hours is one of the great benefits of practicing Emergency Medicine, and is certainly a plus when comparing careers in the various specialties. Knowing in advance (and having some control over) when one is working or not, as well as when one can go home at the end of a shift distinguishes the Emergency Physician's schedule from that of the traditional physician's. These benefits, however, do not mean that the hours worked are "great." On the contrary, most of the hours are late at night, on the weekend, or on holidays. A quick attendance-check at 3AM in the hospital will reveal that, except for the periodic presence of the General/Trauma Surgeon and Cardiologist (both being true work-horses of medicine), all but the Emergency Physician are tucked safely in bed.
Also pertinent is the stressful and demanding nature of the Emergency Physician's shift. Office-based physicians generally work more total hours than Emergency Physicians; however, their hours are spent in a variety of ways, some more demanding than others. For example, Internal Medicine Physicians typically have a longer workweek, but this includes administrative tasks, doing rounds, and seeing patients in the office. The patients in the office tend to be known entities with a few new patients added on each day. The day is broken up and has some lower-stress duties. Emergency Physicians, on the other hand, continually evaluate and treat new patients, starting each case from scratch with a myriad of stressors added in. The result is a physically and mentally high impact shift, necessitating a shorter workday.
Because of the late shifts, the "Bounce Back Factor" must also be considered when comparing lifestyles of the various medical specialties. One must be careful not to overlook the importance of the reentry (or bounce back) period after working late or all night. Young people can burn the candle at both ends, but long-term survival in the specialty requires adequate time to bounce back after working all night. An Emergency Physician's schedule, seen on paper or through youthful eyes, can appear quite nice (lots of time off!); however, do not forget to account for the Bounce Back Factor! Some of those "days off" are actually spent sleeping, feeling exhausted, and resetting one's Circadian rhythms.
Also unique to a career in Emergency Medicine is the difficulty in improving one's schedule as one advances in age. Most physicians start out in practice working huge amounts of hours and taking frequent weekend and holiday call. As they become established, however, they commonly join groups or take on partners, spreading the call days over a larger number of individuals. Thus as one gets older (and less tolerant) call becomes less frequent. With five partners for example, one may be required to take call only one weekend a month and one or two major holidays a year. Emergency Physicians, on the other hand, generally do not receive scheduling benefits from tenure and expanding groups; therefore, the nights, weekends, and holidays persist throughout one's career. Decreasing one's total hours (and thus pay) or going administrative are the only ways to reduce the obligation.
The important thing to keep in mind when considering the lifestyle of an Emergency Physician is that it is different from that of the other specialties, not necessarily better or worse. There are positive and negative aspects, and to look at either in isolation is to miss the point. Early in my career I would savor my days off hanging around the house and reading on my front porch. One sunny day a neighbor kid wandered over and innocently asked me if I had a job. It struck me as funny, but it also underscores the fact that from the outsider's perspective, Emergency Physicians have it pretty good. This perspective is based on a traditional Monday through Friday workweek, and is anchored by the weekends and holidays with nighttime for sleep. The Emergency Physician's hours are spread over a 24-hour day, 365 days a year, giving the appearance of big blocks of time off. Much of this time off is during the week, but in effect serves as the weekend. Being home on week days can allow parents unique opportunities to be involved with their children and spouses, or sports fans to catch a day game, for example. On the other hand it also necessitates frequently missing the weekend activities in which the majority of others routinely participate. Furthermore, as one's family grows and gets busier it tends to be on the traditional Monday through Friday schedule. The result is involvement in activities not traditionally accessible to busy physicians (I served as the Tuesday Paint Parent in all three of my children's kindergarten classes), and absence from those typically attended by one's friends (how many Saturday games and Memorial Day barbeques have I missed?)
Emergency Physicians thus have more predictable and generally fewer total hours than most physicians, but not necessarily easier schedules. They exist in a world outside mainstream society and the traditional workweek. There are no weekends- just workdays and days off. They are often working when others are celebrating, relaxing, or sleeping, and visa versa, which can give the appearance of an easy schedule. There are benefits as well as disadvantages to this setup, and it is important to consider both when making value judgments regarding the lifestyle of a career in Emergency Medicine.
"And you run and you run to catch up with the sun, but it's sinking
Nowhere in medicine is time more important than in the Emergency Department. A constant awareness of time by the Emergency Physician is a critical part of the practice. Nearly every measure of quality regarding the patient's care in the Emergency Department has some component of time attached to it. For example, the number one complaint emergency patients have regarding their Emergency Department experience is that it takes too long. Quicker turnaround times mean more satisfied patients and thus higher quality. Furthermore, it is well accepted that the most important time-period, from the patient's perspective, is the time from presentation to the moment they are seen by a physician. In other words, a patient seen immediately by the Emergency Physician will be more satisfied than one who waited to be seen, even if the total time in the Emergency Department is the same. The Emergency Physician must therefore strive to see each patient as soon as possible after presentation, and arrive at the disposition as quickly as possible.
A rapid course through the Emergency Department improves more than the individual patient's satisfaction. As turnaround times shorten, patients waiting to be seen can be moved into the Department sooner, and in turn their satisfaction improves. With shorter waits, serious medical problems are identified and treated sooner and again quality improves.
Certain medical problems require timely identification and treatment. The sooner an acute myocardial infarction is diagnosed, treated and reperfusion obtained the better. Time is in fact myocardium. When treating serious infections, such as meningitis, pneumonia, and sepsis, early initiation of antibiotics can be critical. Many other medical problems have improved morbidity and mortality rates associated with rapid diagnosis and treatment. In the Emergency Department time often equals quality.
The Emergency Physician is therefore under the gun to evaluate, treat and admit or discharge patients as quickly as possible. When this is accomplished the beneficial effect is transferred to all patients as beds open up sooner and patients are seen more quickly. This is referred to as "moving the room." Conversely, when patients have prolonged Emergency Department stays the negative effect is also transferred to all as patients begin stacking up in the waiting room pending Emergency Department bed availability. Test ordering can have a similar "snowball effect" on the flow of patients through the department. Avoiding extraneous test ordering keeps the ancillary departments from getting bogged down, allowing quicker turnaround times. It has been said that the Emergency Physician is the "Captain of the Ship". What this means is that the Emergency Physician is responsible for all that goes on in the Emergency Department. An efficient style that takes into consideration the effect individual case-management has on all patients in the Emergency Department is a key element of excellence in the practice of Emergency Medicine. Rapid and efficient assessment, treatment, and disposition of each patient results in patient satisfaction, decreased morbidity and mortality, and less congestion and chaos in the Emergency Department. Time and quality are thus synonymous.
Finally, it is important to realize the importance of showing up on time when working in the Emergency Department. As shift workers Emergency Physicians rely on their colleagues to show up on time and provide relief or extra manpower as scheduled. Failure to do this places a burden on one's colleagues and obviates one of the best aspects of being an Emergency Physician- going home on time. Tardiness is therefore unacceptable, especially when replacing a colleague expecting to go home at the end of a shift. Everyone's time is important.
Thus when entering the Emergency Department it is imperative that one shows up on time, practices efficiently and heeds this battle cry: Hurry up!
What is it that we expect from a medical student or resident (or Emergency Physician for that matter) working in the Emergency Department? I posed this question to my friend and colleague Lynette Doan-Wiggens, MD who immediately replied, "They need to be able to synthesize and multitask." The more I consider what she meant by this, the more I agree.
Students and residents rotating on the various services typically are encouraged to be current with the literature, display a solid knowledge base, and have good clinical and differential diagnostic skills. In the Emergency Department these qualities are valuable; however, it tends to be the utilitarian manner in which they manifest that is more important. Thus it is one's ability to apply these skills, assimilate what is at hand, and come up with a coherent assessment and practical plan for each case that is emphasized, rather than demonstrations of one's general knowledge and ability. To synthesize means to produce by combining elements, and it is the product (the assessment and plan) of the combined elements (history, physical, psycho-social issues, urgency, differential) that we are interested in. One's knowledge and understanding should be evident in the way that the case is presented, documented, and ultimately handled. In the Emergency Department actions speak louder than words. For example, any physician worth his salt should be able to come up with an adequate history, physical, and broad differential diagnosis for a patient with chest pain. But the continual pressure of newly arriving patients necessitates that this diagnosis-based approach become disposition-based. The patient cannot stay in the Emergency Department indefinitely. Time-consuming work-ups for wide ranging differential diagnoses need to be avoided or completed elsewhere whenever possible as they contribute to chaos and stagnation. The real question is not what is the diagnosis, but what needs to be done? One must come away from the patient with an idea of what is going on and a focused plan synthesized from whatever information is available. This plan must have vision, seeing the patient through to the appropriate disposition (discharge, admission, operating room, etc.). Every test or consultation should be obtained for a reason, and the course of action anticipated depending on the results. Open-ended test ordering should be avoided. Accordingly, if the patient with chest pain has risk factors, ischemic symptoms, and a normal EKG he needs to be admitted regardless of the cardiac enzymes. Certainly enzymes should be obtained, as the admitting physicians will use the results to guide management; however, waiting for the results before committing does not make sense. Measures directed at initiating appropriate care and facilitating the admission should be started at once. Likewise, instead of discussing pulmonary embolus in the differential diagnosis, it would be better to let the documenting speak for itself. If there is no calf tenderness or swelling, normal vital signs and a pulse oximetry of 100%, I get the picture. Take the data and synthesize a story that not only has a beginning (history and physical), middle (diagnostic studies and consultations), and end (disposition and treatment), but also makes perfect sense. The more one is able to accomplish this, the better suited for the Emergency Department one will be.
The ability to multitask is the other half of this formula for success in the Emergency Department. The term is borrowed from the computer world where it is used to describe a computer's agility. Similarly, effectiveness in the Emergency Department is reflected in one's ability to do many things at once. The most obvious factor is one's ability to see many patients at a time- the more the better; however, one must also be able to efficiently steer each of these patients through the Department to their appropriate disposition. Simply seeing many patients and holding on to them does not cut it. One must also be able to evaluate data as it arrives in a piecemeal fashion, and act on it; continually discuss and explain the situation to nurses, patients, and families; integrate the involvement of consultants, special studies, and treatments; consult resources; document; answer phone calls; deal with incessant interruptions; and arrange for discharge or admission. In addition, while multitasking in this manner the Emergency Physician must always have the means to take additional critical and life-saving actions as unexpected situations can be thrown into the formula at any time. The ability to multitask is therefore a critical component of effectiveness in the Emergency Department. Some are born with this ability, some are able to acquire it, and others simply cannot do it (do you find that a stick of chewing gum serves as effective birth control?).
What is expected in the Emergency Department? Nothing short of everything. How does one achieve this? There is no certain formula, but while remembering the Emergency Physician's battle cry (Hurry up!) it might help to also make note of the following motto: Synthesize and multitask!
"If you have a good name, if you are right more often than you are wrong, if your children respect you, if your grandchildren are glad to see you, if your friends can count on you and you can count on them in times of trouble, if you can face your God and say 'I have done my best,' then you are a success"
Most Emergency Physicians prefer anonymity. The current of gratitude and recognition from patients and colleagues that most physicians enjoy typically bypasses the ED. Instead, we know that unsolicited feedback concerning our patients is usually gloomy. No news is good news, but bad news never fails to find us. We also recognize that bad news will follow the question, "Do you remember that patient you saw yesterday?" Sooner or later all Emergency Physicians are faced with this ominous question, and after a dreadful private moment the bitter pill of responsibility is swallowed. Whether or not the patient is remembered, however, is not the point. The point is that something bad and unexpected happened and you were in charge.
These terrible and unexpected things are often referred to as "bad outcomes." Because the practice of medicine is an inexact science, bad outcomes despite proper care are a reality. Because the realities of medicine are typically magnified in the ED, our bad outcomes tend to be really bad. Despite good training and sound decision-making a subset of our seemingly well patients will, much to our shock and dismay, unexpectedly become infected, bleed, perforate, rupture, infarct, or dissect. A colleague of mine once described these as "bad luck cases" (bad luck for both the patient and physician.) When these things happen, some patients (or their surviving family members) will find an attorney and sue. The good news is that most bad outcomes do not result in lawsuits. The bad news is that when they do, it becomes a nasty and dirty business, and the nastiness and dirt will be directed squarely at the physician.
In theory, for a malpractice lawsuit to be successful the plaintiff (the patient) must allege and prove four things: preexisting duty, breach of duty, damage and causation. In other words they must show that the offending party (you): had a professional duty, failed to comply with the minimum standards of your specialty, and directly caused injury or loss by neglecting to render this "standard of care." The standard of care is the care that would ORDINARILY be provided under similar circumstances as those of the evidence. This is reassuring, as it seems that one can avoid a successful suit by simply practicing medicine the way one has been trained, i.e.: within the standard of care. Unfortunately the reality is not that simple or comforting.
Experts are hired by each side to define the standard of care. These experts are paid handsomely, including some for the plaintiff who make hundreds of thousands of dollars each year providing expert opinions. An expert witness industry has actually developed in which some physicians can earn over 90% of their income performing this service. At trial a jury of THE PLAINTIFF'S peers, rather than the defendant's, will decide who is right. A jury of cocktail waitresses and software designers will not likely understand the nuanced and data-fueled world of physicians; therefore, they will consider the case in terms of general themes presented by the lawyers, as well as whether they find the physician to be careful, compassionate, and qualified. Subtle factors can sway them one way or another.
Also, a suit may be filed for any reason. Only its success is tied to the standard of care. Once a malpractice suit is filed, it leaves the world of medicine altogether- with our data, logic, and attitudes- and enters the confusing and powerful world of lawsuits. This is a high-stakes world of strategy. It is focused on huge amounts of money to be won or lost, and what each side believes they can convince a jury of non-medical people to understand and believe. Countless factors come into play as each side maneuvers. The plaintiff has a "lottery mentality" in that there is nothing to lose, and a sympathetic jury may decide to award them massive amounts of money. The plaintiff's lawyer also has this mindset (a third of the money generally goes to the plaintiff's lawyer); however, it is tempered by the fact that there will need to be an investment of time, hard work, and dollars, and as the case drags on all of these expenses increase exponentially. An early settlement may be appealing to the plaintiff's lawyer if winning at trial appears unlikely. The physician must also consider the likelihood of victory, as well as the stress and emotional strain of a tedious and very personal trial, time off work, and the fact that either a pre-trial settlement or guilty verdict will be recorded for public viewing in a national registry. The defense attorney must consider the probability of winning the case at trial, and compare this with the settlement offer and the real likelihood of a lottery-sized award if the case is lost (with the unpredictability of juries, there is always a chance of a huge award.)
Each party will analyze the risk/benefit ratios as the process of discovery exposes the facts and expert opinions. As the trial approaches, the gravity of the situation increases. Out of this complex soup will come a settlement or trial. It can become a mean and aggressive game of strategy and nerve with the defendant physician's insular point of view factoring in only partially.
Confusing things even more for physicians is the bias of their medical culture, which often suggests that all malpractice suits are frivolous. This is not true. Malpractice suits have forced doctors to change and improve the care that they provide. This is a good thing. Furthermore, malpractice does occur and it needs to be policed. The dilemma is that many of the genuinely mismanaged cases are not identified, and that many of the suits involve cases with bad outcomes but no wrongdoing. The system is thus designed so that rewards and punishments are doled out in a manner that does not correlate with what most physicians consider to be fair. The system also is quite lucrative for trial lawyers who as a group are politically influential; hence, the likelihood of significant change is small.
Thus, physicians must accept the eventuality of being sued, and know that the end-result may hinge on factors out of their control and foreign to their worldview. A suit may occur at any time and be won, lost, or settled for any reason. This may come as a shock to some, but the reality of being a doctor is more than Cadillacs and country clubs. Getting sued is a part of our business. Furthermore, we must accept that some lawsuits have forced doctors to change and improve their practices.
Martin Luther King Jr. said, "I have always felt that ultimately along the way of life an individual must stand up and be counted, and be willing to face the consequences, whatever they are, and if he is filled with fear, he cannot do it." D o not allow the fear of being sued to be the driving force of your medical practice. Such fear can stifle and ruin a physician. Instead, practice as you were trained, and always put forth your best effort. If a bad outcome occurs, stand up and be counted.
The care ordinarily provided by reasonably well-qualified physicians when they apply their knowledge and skill under similar circumstances as those of the evidence.
Tips For Testimony:
When I was a senior resident at Christ Hospital in Oak Lawn, IL, we were having a typically horrendous evening. The place was packed, critical patients were everywhere, and there were many more lined up in the waiting room. I felt responsible, over-worked, stressed, and it all seemed so out of control. I then received a telemetry call reporting two patients with gunshot wounds to the chest coming our way. My reaction was one of dread, frustration and anxiety, as I believed the knockout punch was coming. I was concerned with the huge amount of work we had and felt that we would never get through it all. I approached the Attending, Dr. John Shufeldt, and anxiously explained the predicament, expecting his reaction to be similar to mine. Instead he looked at me, nodding his head- a twinkle in his eyes and a grin on his face- and said, "Cool."
At that moment I realized that he was right. It was cool. We were about to have two patients with gunshot wounds come to our Emergency Department. Sure we were busy, but think of the experience. Very cool.
What I learned from John was that medicine, and especially Emergency Medicine, is supposed to be fun. When faced with the cacophony and irritation of a busy room, constant interruptions and a seemingly insurmountable amount of work, it can be easy to forget; however, with the right attitude and a little effort not only can we remember it is supposed to be fun, we can make it fun!
It is interesting that the aspects of Emergency Medicine that initially attract us to the field subsequently are often the things that stress us out. As medical students the shift work, fast pace, chaos, and wild and varied nature of the patients and practice are appealing and fun, especially to the young cowboy-minded student not satisfied with the idea of traditional medical practice. As we age, however, these same things can begin to grate on our tolerance, becoming stressors and ultimately causing us to forget why we entered the field in the first place.
Eighteenth century English author and critic Samuel Johnson said, "The fountain of content must spring up in the mind, and he who hath so little knowledge of human nature as to seek happiness by changing anything but his own disposition, will waste his life in fruitless efforts and multiply the grief he proposes to remove." Dr. Johnson was astutely telling us to concentrate on our attitude and outlook rather than our situation. Nowhere is this more helpful advice than in an obnoxiously busy Emergency Department, in the middle of the night (on a holiday?) as one prepares to work through a stack of patients with complicated and seemingly bizarre complaints. Under this duress it is easy to become cranky, irritable and to lose sight of the fun in medicine.
Interestingly, it is just these situations (busy nights, complicated and difficult patients, etc.) that our non-medical friends and family want to hear about when they ask for "ER stories." They, like the medical students, are fascinated by Emergency Medicine. Night shifts are tough, patients difficult and the workload overwhelming at times, but these things can make the job interesting, unique and yes fun. The Emergency Physician is there at a crossroads where all elements of society and human experience meet, stepping in with the authority and experience to direct the situation to its most reasonable resolution. Executives, manual laborers, homeless people, cops, firemen and paramedics, all races and creeds, and people of every age come together in the Emergency Department looking for help from the Emergency Physician. Millions of people tune in regularly to vicariously experience what the Emergency Physician is paid handsomely to do.
So when under the gun, try to remember why you chose to go into Emergency Medicine, and what Dr. Johnson said. Also remember that as far as jobs go, practicing Emergency Medicine is pretty darn fun if you look at it right. The key is, when faced with adversity, to take a deep cleansing breath and say to oneself, "Cool."
(Or It's Supposed To Be Fun: Part 2)
Most medical students choose their specialty during the third or fourth year after completing a circuit of clinical rotations. The many years of toil, study and delayed gratification finally result in the first big payoff- the opportunity to simply choose one's career. Up to this point most students have conformed to varying degrees in order to survive and succeed. When finally granted this complete freedom to decide, some students (in true medical student fashion) over-analyze things and turn a fairly straightforward decision into an endlessly complicated one.
You will recognize these students immediately. They will be heard saying things such as, "I really like Emergency Medicine and think the lifestyle is great but I think I would miss the continuity of care and wonder if I will get enough procedures. It would be awesome to be a Surgeon but I don't think I could handle the residency," and so on. These individuals should be avoided. Such micro analyzing is confusing and contagious. They are placing undo emphasis on particular aspects of the specialty in question and viewing them in simplistic, black and white terms.
Most of the issues obsessed upon in this manner are double-edged realities of the specialty; in other words they are both good and bad depending on how one looks at them. For example, the desirability of continuity of care may depend on the patient. Is the midnight call from your agreeable and appreciative patient or the demanding and non-compliant one? Workload issues also can be deceiving. A demanding surgical residency does not have to translate into a workaholic career. Thus attempts to itemize the nuanced complexities of a career in any specialty will miss the forest for the trees.
The big picture is that all doctors work very hard. There is no way to have a successful career as a physician and not work your butt off; therefore you had better be interested and excited about the specialty you choose. Lifestyle, money, residency and specific aspects of the specialty are side issues in comparison to one's passion for the medicine itself. If you choose Dermatology without a keen and tireless interest in diseases of the skin, all the perceived positive aspects of being a Dermatologist will be overshadowed by the nausea and dread you experience as you drive in for a 40-patient clinic day. Likewise without a love of EM, the "great" lifestyle will not seem as great as you wrestle with a drunk at 3AM Christmas morning.
Happy and successful doctors love their specialty. They enjoy the positives and tolerate the negatives as necessary but not overwhelming evils. When deciding, simply ask yourself what field of medicine interests and excites you the most? On which rotation were you the most motivated and willing to read and learn? Where did you feel most at home? Answer these questions and your choice will be obvious.
Emergency Medicine is unique in that non-Emergency Physicians are eager and willing to express their opinions regarding the specialty when in fact they often have little basis for these opinions. Physicians who are not Emergency Physicians frequently offer students advice, insight and criticism regarding the specialty in general, the EM match strategy, and the actual practice of EM. Unfortunately these opinions are coming from individuals with no first hand knowledge of EM, are usually negative or critical and should be avoided or at least ignored.
There is something about EM encourages people to believe that they understand what it is about and know how it should be practiced despite not having been properly trained in EM and not actually practicing it. Physicians will sometimes relate that they considered EM as a career or that they worked in an ED during their training or early in their career.
The situation is further complicated by the reality that the work force needs in America for staffing of all the EDs cannot be met entirely by EM trained and Board Certified Emergency Physicians. Thus many hospitals must find other doctors to staff their ED. These doctors are not Board Certified in EM and generally have not been trained in EM. Such Physicians consider themselves to be Emergency Physicians through experience, and in many ways they are; however, they will never be Board Certified in EM and generally take jobs not filled by Board Certified Emergency Physicians. These jobs tend to be rural, inner city or at VA hospitals. Students might be advised, therefore, that a reasonable alternative to matching in EM would be to match in something else, such as Internal Medicine, and simply work in an ED. This is an option, however one must realize that with this track there is no way to become Board Certified in EM and the best jobs and career opportunities in EM would be off limits. This is not an ideal approach to a career in EM. Similarly any physician with a license can practice Primary Care, yet it would be wrong to advise a student interested and motivated by Primary Care to train in EM and then open a clinic. A student interested in EM should strive to match in EM and become Board Certified.
Emergency Medicine is practiced in a fishbowl. That means that everything we do is public and open to scrutiny, even by individuals who do not fully understand what it is we are about and doing. Unlike other specialties everyone seems to have an opinion about EM and is willing to express it. Keep an ear out for such opinions and politely question the basis for them. More often than not you will find there is none.
For reliable and valuable advice and information regarding EM students should speak with Board Certified Emergency Physicians, EM residents and students who themselves are aiming to match in EM. All the rest is just blah, blah, blah.
After deciding on a specialty and looking into residency programs you will need to decide how to rank the various programs on your match list. Deciding which program is "the best" can be difficult as countless issues come into play. Furthermore, the opinions of well-intentioned friends and faculty as well as word-on-the-street reputations of programs may sway you.
The important thing to remember is that only you can decide which residency program is best. This is because only you can define what the most important factors are. Thus some may view a program with a strong reputation for research and high academic standards as desirable, but others may be more interested in non-academic issues such as clinical experience or quality of life. Location may even be the over-riding factor. When I applied for residency I was married with a child on the way. Moving out of the Chicago area and away from family (whose support would be critical during my long work hours) would have been quite difficult for my wife. By definition Chicago-based programs were "the best" in my eyes.
It is critical to introspectively and honestly examine your priorities in terms of your own situation, goals, desires, abilities, and limitations and to be true to yourself when making decisions. Do not allow yourself to be pressured by others who have their own definition of "the best" program. If you plan a career practicing in the community an academic program may be less desirable. Similarly, if geography or quality of life are vital then look for programs that meet these needs. If your thought process is clear and true, then you can be confident and proud that your top-ranked program is in fact the best.
Similarly, when you complete your training you will need to find the best job. Certain factors such as pay, impressive facilities, location, or the commute may leap to the forefront to suggest that certain jobs are better than others. Again you must be honest with yourself as to what it is that you are looking for. Is it money? Lifestyle? Career advancement? Academics? Location? Rather than finding all the available jobs and trying to fit into one of them, decide what type of job, career and lifestyle you want and find something that fits that. Be willing to re-examine things over time as your priorities can change during your career. A high paying job with little opportunity for career advancement, for example, may be more or less appealing at various stages of your career. Forcing yourself into a job or corporate culture for the wrong reasons is a recipe for frustration at best and disaster at worst.
An Internal Medicine Physician, a Surgeon and an Emergency Physician are duck hunting. A duck flies by and the Internist asks, “What is it? Is it a duck, a goose, a pheasant?” He aims, fires and kills it. He picks it up and exclaims, “It’s a duck.” The Surgeon readies himself as the next duck flies over and announces, “Look, it is a duck.” He immediately fires and kills it. He picks up the dead bird and says, “Have this taken in and identified.” A third duck flies over. The Emergency Physician leaps to his feet, fires and kills it, then asks, “What was it?”
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