A ten year doc’s advice to newly graduated EM residents…

Recently, I blogged about being at my new job for 10 years. It was a wonderful experience to blog about stability. It’s also illuminating I’ve been here for 10 years and still call it my new job.

Not long after the blog post went up, I got an email from a soon to graduate Emergency Medicine resident who was curious as to what techniques I have used to stay at the same job for 10 years. This caused me some consternation, as I don’t think I really had an actual plan to be at the same place for this period of time. Emergency medicine practitioners are not known to stay in the same place for a long time, so blogging about a 10 year stay is something of an anomaly.

When I was a resident the common knowledge given was that it was important to serve on hospital committees, and to otherwise do a good job and you would be recognized and your life would be fine. This may or may not be true for everyone. I did find that I was on hospital committees, but it was after I’d been here for more than eight years and was interested in serving on them. One of the unusual things about my group is that there is extraordinary longevity, and I’m still basically middle of the pack having been here 10 years. I realize this is atypical for emergency medicine, but I think it will become more normal to have more job longevity as the emergency medicine field matures, and as there are more graduating residents.

What you’ll find helps you in the long run in emergency medicine is being a good colleague to the medical staff. This is somewhat antithetical to the way we’re trained, which is this low-level combat between departments, but ultimately the rainmakers talk to the hospital President, if your group isn’t making it some other group will. This does not mean you have to be a doormat but it does mean that when a consultant calls and asks you for a favor if it’s not unreasonable you should do it. This isn’t bad medicine, this is actually good medicine because you’re helping a smart colleague help out their patient. This service does not go unnoticed. In fact, if you want to stay in your place for a long time, be known to be helpful.

Being competent, you’d think, would be a given; you’d be wrong. Being competent in your job, and collegial with the nurses and staff, goes a long way to being accepted as one of the group and being one of the group means you get to stay.

Nobody wants their doctor to be having a bad day. Nobody who works there wants the ER doctor to be having a bad day. It doesn’t matter that your cat threw up in your shoes, or that your underwear is too tight, you have to try to get along. I’m not going to lie to you and tell you that I’m all roses and sunshine but I’m trying every day to get better at this.

Your reputation is set early, take advantage of that. I have a reputation for always being early; these days I’m about on time. For the first six months, I was about 10 to 15 minutes early for every shift. But, since I was always early initially, my reputation is set. On the same theme, as a colleague says, two minutes late is not on time, it’s very very late. When you’re working your tail off, you don’t want to be wondering when your relief is coming in. You’re very important; so is every single person you work with. Never forget that.

New grads are always interested in, and worry about, hospital politics. Here’s the short version of hospital politics in your first two years of practice: don’t make the directors’ job hard. That’s all you have to do. Just show up, work, practice good medicine, and don’t make the director’s job hard. The director is in that position for a reason; as a matter of fact, they’re so smart they hired you, so you should give them the benefit of the doubt when the iffy call comes out. They don’t want you to bother a certain specialist after a certain time; there’s a reason for that, and you should have a conversation behind closed doors, not at the nurses station.

And, when you do finally step in it, and make the mess that’s going to show up on the directors desk sooner or later, you need to be the one that has the conversation with the director first and they don’t need to hear about it from anyone else. This is basic leadership and you need to get on board with it. If they have the facts, and have your side of the story good or bad, they can help you; if they get called on the carpet and have to defend you not knowing your side of the tale, you will not come out the better for the experience. This is just the way of the world, it’s been the same way since you got punished for your brother knocking over the lamp. Help the guy who’s got to help you.

Also, when you show up, you’re going to be full of new knowledge. This doesn’t mean you’re smarter than the group, this just means you got out of training more recently. Use your new power for good and not for evil. And as you’ve probably guessed, there are about 30 ways to skin a cat, and you got trained in two. Keep your eyes open, and learn from your colleagues. They want to help you, let them help you.

Finally, have a life. Don’t spend all the money, put some away, as you may be like me and have to change jobs the first year. It happens. It happens to a lot of us; this doesn’t mean you’re bad it just means it was a bad fit. Keep trying.

Most of that was platitudes; sorry about that. The realty is if you’re a good person, do a good job, and play well with others you’ll be fine.

 

This was written with the new Mountain Lion operating system for the iMac; it was dictated and now you know that I don’t speak well.

 

Ottawa ankle rules and me

@ @ @ Ottawa Ankle Rules? People follow them? :) I try to explain to pts but really, they want an XR

This reminds me of my experience with the Ottawa Ankle Rules in the Navy.

USMC Infantry is designed to generate ankle sprains, and recurrent ones. Initial sprains as young athletic hard chargers are required to carry big loads over unimproved terrain in the dark, plus seemingly all the time not in direct training was spent running.

The larger problem, and one I was educated on by a fellow BN Surgeon (who was a physical therapist prior to med school) while in Okinawa is that there’s no ankle rehab after a sprain. As soon as you can run on it you do, despite having torn stabilizing ligaments and not having done the training and exercises to get the ankles’ accessory stabilizers up to speed. Then, another sprain. The story of how our medical department got this fixed later.

Sick Call was musculoskeletal city with daily ankle sprains, which by that time in the Marines were usually recurrent. About a year into my assignment, out came the Ottawa Ankle Rules. After a year of negative x-rays, finally, a clinical tool to cut down on useless imaging! I used it in practice, taught it to the Corpsmen (who also found it usable and liked it) and our x-ray utilization dropped hugely and AFAIK we didn’t miss any significant fractures. I was proud.

I was moonlighting (for free, I was that bored) in the Camp Pendleton Naval Hospital ED, and mentioned my new practice and how I was proud to have made an impact.

The response: Please stop doing that. Now when they get off duty they drive down here to get an x-ray”.

Humbled, we backed off a little, but not much.

My response to the above tweet (which I now think I recall as being an @nickgenes original) was “Canadians get exams, Americans get x-rays”, which sums it up nicely.

 

ABEM ConCert prep course recommendations?

This is my renewal year for ABEM, and as you can imagine I just want to take a $1,700 test once (you read that right, that’s my cost to voluntarily take a test to remain Board Certified). (Board Certified rant pending).

What have other ABEMers taken, either as in-home or travel-to courses that you’d either recommend, or scare me away from? I’d actually prefer a travel-to course (fewer distractions), but am open to whatever works best.

Please add a comment, or send me a message through the ‘contact’ form.

I’ll let you know how it comes out.

 

Texas Pharmacy Database now searchable

Texas docs (and pharmacists, etc…) you can, after a registration, look up an individual and see what prescriptions they’ve had filled.

Texas DPS Prescription Access Texas (PAT): https://pat.dps.texas.gov/Login.aspx

Here’s your power tip: have your Texas DL in hand, as it’s not just your DL# they want, but that long, goofy number that’s aligned vertically alongside your photo. (Which you’ll need every time you log in).

Yes. Texas has caught up with West Virginia. Come for the info, stay for the snark.

A Death Knell for Press Ganey? | WhiteCoat’s Call Room

Not only does “satisfaction [have] little or no correlation with Health Plan Employer Data and Information Set quality metrics,” but, according to the results of this study, hospitals that push to have the highest satisfaction scores may be harming or even killing their patients.

via A Death Knell for Press Ganey? | WhiteCoat’s Call Room.

I’m not ever going to get tired of this.

Skeptical Scalpel: Patient satisfaction and reality

You. Don’t. Say.

Christmas came early for us skeptics this year. In a landmark study, certainly one of the most interesting and thought-provoking of the year-to-date, researchers from the University of California-Davis found that the more satisfied patients were with their physicians, the higher their hospital admission rates, prescription costs and total costs were. And patients with the highest level of satisfaction with their doctors had higher mortality rates compared to those patients least satisfied with their doctors.

via Skeptical Scalpel: Patient satisfaction and reality.

Anecdotally, I think that the push for higher patient satisfaction has led directly to underperforming docs doing things they wouldn’t normally do. This isn’t good medicine, it’s playing a very dangerous game.

Grand Rounds: February 14th, 2012–Valentine’s Day version

To those who submitted posts, I say thanks. I appreciate that you did. Medical Grand Rounds keeps going because of you, the medical blogger. Your voice, your impressions, your passions and your human stories make our field such a great canvas.

via Grand Rounds: February 14th, 2012–Valentine’s Day version.

I actually submitted this time around.

Anyone know the ongoing volume/edition number?

CARPE DIEM: Do Medical School Acceptance Rates Reflect Preferences for Preferred Minority Groups?

Interesting.

1. For those students applying to medical school with average GPAs (3.40 to 3.59) and average MCAT scores (27-29), black applicants were almost three times more likely to be admitted than their Asian counterparts (85.9% vs. 30%), and 2.4 times more likely than their white counterparts (85.9% vs. 35.9%). Likewise, Hispanic students…

via CARPE DIEM: Do Medical School Acceptance Rates Reflect Preferences for Preferred Minority Groups?.

Pride is a Fall Risk

Stick with it.

I’m good at intubating (the procedure by which a tube is passed through the vocal cords into the trachea to assist ventilation). I’m not the world’s expert, and I haven’t written a book about it, but I know what I’m about. I was trained by people who knew what they were doing, and I (and my patients) owe them a debt of gratitude. (Lotta I’s there, sorry).

Very occasionally, I get to help out my partners in Emergency Medicine practice when they’re in a bind with this procedure, and I do.  It’s always fun, and a little gratifying, to ‘get the tube’ when a colleague (and their patient) is in trouble.

As Ron White says, “I told you that story so I could tell you this one…”

Pride goeth before the fall.

I have come to learn that one of the worst sins of a physician is Pride. This is strictly different and separable from confidence, in that confidence is a normal and rational belief in ones self and abilities whereas Pride is based in ego, irrespective of confidence. Or logic, for that matter.

The worm turns, and I’m the one who cannot get the tube in the trachea. I’ve preoxygenated, sedated, RSI’d, and taken 3 tries. I’ve changed tubes, blades (the laryngoscope has differently sized and shaped blades), and patient positioning which are among the things that should be adjusted in the event of intubating failure. The good news? This patient can be oxygenated and ventilated easily with the bag valve mask. The bad? I’m now no closer to getting the airway secured with a cuffed tube than I was when I started.

This is where not having Pride came in: I asked for help. The Prideful EM doc (or the one in solo practice, and I respect the heck out of all of you) will keep trying, and will eventually help the patient and assuage their ego (or their situation) by getting The Tube. This can come at a cost to the patient in airway trauma or worse, and it’s desirable to avoid that.

My colleague physician came in, smiled, and helped my patient and me out of a bind. Colleague made it look ridiculously easy, with a first attempt intubation. Just like I’ve done before…

He was amazingly humble, and didn’t rub my nose in my failure to intubate. I truly hope I’ve been as nice to my colleagues in the same situation. Really, he was as nice as a human could have been while pulling chestnuts from a fire. Mine, to wit.

And I surprised myself by asking for help with a procedure I’m normally good at. No Pride, no Ego, just what’s good for the patient. I’m getting this Doc thing.

 

Interactive: Who Are the Uninsured in Texas?

Nearly a quarter of the Texas population lacked health insurance in 2010, according to the most recent data released by the American Community Survey, which the U.S. Census Bureau conducted. That’s more than 5.7 million Texans.It’s likely that someone you know — and probably one you wouldn’t have guessed — doesn’t have health insurance. More than half of the uninsured are employed. More than a third have an annual household income above $50,000. And more than 1 million have college experience or post-secondary degrees.

via Interactive: Who Are the Uninsured in Texas?.

Very nicely done.

If I get a lesson from this, it’s “Stay in School. kids!” (If you live that long).

Doc Fix Just Got More Expensive

Sustainable. They keep using that word. I do not think it means what they think it means…

Permanent repeal of the flawed Medicare payment formula known as the Sustainable Growth Rate just got a lot more expensive….

via Doc Fix Just Got More Expensive – Margot Sanger-Katz – NationalJournal.com.

The Worst Quackery of 2011: Battlefield Acupuncture – Forbes

So: the 2011 winner of the worst quackery award is: battlefield acupuncture. This bizarre practice, invented just 10 years ago, offers a trifecta of ills:

It offers no medical benefit and carries a real risk of harm for some patients.

The U.S. government is wasting tens of millions of dollars per year on it, and plans to increase its spending next year.

The patients are wounded combat veterans who have no choice about where to get treatment.

In battlefield acupuncture, the “doctor” (no competent doctor would do this) sticks needles into the patient’s ear to relieve pain.

via The Worst Quackery of 2011: Battlefield Acupuncture – Forbes.

Incredible. And infuriating.

(Found on Twitter, but I cannot recall who tweeted it).

Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA

Wow. Short, and sweet, and painful.

…peddling the same tired phenomenon of magical thinking regarding the diagnostic miracle of highly sensitive troponins…

via Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA.

Nice! Go and read.

via @nickgenes on that Twitter thing

With explanatory graphics! The Sources of the SGR “Hole” — NEJM

This article and its graph (from the NEJM), and its interesting, informative but probably useless graph, was referenced today on twitter, via the Washington Post’s Wonkblog,

Recently, the Centers for Medicaid and Medicare Services announced a scheduled cut in Medicare physician fees of 27.4% for 2012. This cut stems from the sustainable growth rate (SGR) formula used by the physician-payment system. …
To illustrate the level of inequity in this system, we broke down the national spending for Medicare physician services by state and by specialty and determined which states and specialties have contributed most to the SGR deficit between 2002, when the program was last balanced, and 2009. Although SGR spending targets are set on a national level, we computed state targets by applying the SGR’s national target growth rate to each state’s per capita expenditure, using 2002 as the base year. Our analysis is an approximation, because, unlike the SGR, we do not adjust for differential fee changes. …

We compared the state targets for the years 2003 to 2009 to actual state expenditures and added the annual difference between these figures to get a cumulative difference between the state’s spending and the SGR target. This cumulative difference was then divided by the 2002 per capita expenditure to determine the percentage growth since 2002.

via The Sources of the SGR “Hole” — NEJM.

Here are the graphs, and my attempts at explanation, and the questions I have:  [Read more...]

Navy HPSP / GMO Query

I got a nice email form someone who stumbled across this Humble Blog, and had the following questions; my replies follow. Those who have something constructive to add, please do so in the comments.

1. I’m most interested in EM. Given that I have no prior military service/experience, am I basically going to have to do a GMO tour to get this specialty?

Well, it depends on a lot of factors. Your branch of service is probably the biggest determinant (AF is best, Navy is historically worst at going from Internship straight to residency without a GMO tour), but there are several reasons you might not want to go straight to residency.

Honestly, residency is easy compared with being a GMO, at least the first year of a GMO tour. I finished a Basic Surgery Internship, and went to the fleet as a Battalion Surgeon (honorary doc title). I could spit out the Ddx of hypersplenism but had no idea how to treat musculoskeletal back pain, an ankle sprain, or PFPS. I’ll get into the rest of this later.

2. Did you do a GMO tour? If so, how was it?

Yes, GMO for 4 years. Fortunately for me it was between conflicts. To plagarize some guy, it was the best of times, it was the worst of times. Seriously, if I could have my GMO job 1/2 time and my real job 1/2 time I’d be a very happy person, and a happy doc.

3. What made you ultimately decide to stay in military post-active duty or leave for private practice?

I wasn’t a career type, and I knew I wanted to work in the real world. At the time new EM grads were going to boats, and while they’d be very useful there were there a shooting war, it would be a punishment tour otherwise.

4. What kind of leadership opportunities did you have in military medicine that you feel would have been impossible/unlikely in civilian medicine?

I got to lead, really lead, some excellent Navy Corpsmen, I got to advocate for some Marines and Sailors who needed it, and I got to go places nobody gets to these days. (2 trips to Iwo Jima, try booking that on Kayak).

5. Would you have decided to still do HPSP if the scholarship amount was significantly smaller? (ie, <50% what it is).

It was that then, I did it because I wanted to serve and it served by desires and interests. In general, if you’re considering HPSP just to pay the bills you won’t be a happy camper, and you’re signing on the line for a lot of years.

6. Is it possible to find out how many GMOs the Navy needs? (Currently, there are rumors that the Navy is going to change the GMO program).

No idea. But, don’t consider GMO time punishment, or time lost, it’s just something different, and I still think of (parts of it) fondly. The bonus of being a GMO and re-applying to a military residency? Time in Service is weighted on your app. So, if you want to be a brain surgeon but were bottom of your class, after a few GMO tours you’d most likely be in (YMMV).

Best of luck with your decision, and please let me know how it goes!