An Emergency Medicine Mindset

This book contains views and opinions of medical providers and in no way should be used as medical advice. It is a look into the mind of emergency physicians. The publisher and authors disclaim any liability for medical contents in this book. The opinions expressed do not reflect the views or opinions of the United States government, U.S. Department of Defense, or U.S. Air Force.

An Emergency Medicine Mindset. Copyright © 2017 by Alex Koyfman and Brit Long. All rights reserved. No part of this book may be used or reproduced in any matter from publishing date without permission from Alex Koyfman and Brit Long.

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Table of Contents

Cover

Title

Copyright

Introduction

Louis Ling, MD

Michael B. Weinstock, MD

Brian J. Zink, MD

Acknowledgements

Alex Koyfman, MD and Brit Long, MD

The Emergency Medicine Mindset

Joe Lex, MD - Thinking Like An Emergency Physician

John P. Marshall, MD - The Twin Challenges of EM Practice

Amy Kaji, MD, PhD - The ED is the Equalizer

Pik Mukherji, MD - Three Defining Factors of EM

Andrew Sloas, MD, RDMS - Emergentologist

Nikita Joshi, MD - An Emergency Medicine State of Mind

Deborah B. Diercks, MD, MSc - The EM Environment

Zack Repanshek, MD - Making a Difference in People's Lives

Rob Orman, MD - The Successful ED Mindset

Sergey Motov, MD - Complex & Dynamic

Daniel Cabrera, MD - The Chaos Organizer and the Fear Tamer

Tim Horeczko, MD, MSCR - To Safeguard, to Comfort, to Guide

Michael B. Weinstock, MD - Not Like Reading a Book at the Beach

Sean M. Fox, MD - Humble Arrogance

Christopher I. Doty, MD - Approaching the World

Charlotte Wills, MD - Black Clouds

Bob Stuntz, MD, RDMS - Developing the EM Mindset

James G. Adams, MD - Frameworks & Habits of an Emergency Physician

Alex Koyfman, MD - A Career Worth Pursuing

Salim R. Rezaie, MD - Building a Successful Mindset

Steve Carroll, DO, MEd - Masters of the Undifferentiated Patient

Rob Bryant, MD - Seven Rules That Make Me Nicer to Work With (When I Remember them)

Seth Trueger, MD - Resuscitation, Risk Stratification, Care Coordination

Sam Ghali, MD - Make Things Happen, Save Lives, Alleviate Suffering

Jason Wagner, MD - The EM Hive Mind

Reuben Strayer, MD - 8 Responsibilities of the EM DOC

Jordana Haber, MD - The Unique Skills

Felix Ankel, MD - A Systems Mindset

Larissa Velez, MD - The Unique EM Mindset

Anand Swaminathan, MD, MPH - Lessons from John Hinds

Aditya Lulla - The Med Student Edition

Education, Leadership, and Cognition in Emergency Medicine

James E. Colletti, MD - Educating Amidst Chaos

Benjamin H. Schnapp, MD - Tips to Becoming a Superior Educator

Judith E. Tintinalli, MD, MS - Reading My Mind

Julie S. Sayegh, MD - Teaching The Modern EM Resident

Justin Bright, MD - Reflections on Leadership and Resiliemce in Emergency Medicine

Jeff Riddell, MD - Two Crucial Non-Clinical Cornerstones

James O'Shea, MD - Cognitive Load and the Emergency Physician

Christopher Hicks, MD, MEd - The Thinker and Human Factors

Justin Bright, MD - The Multiple Layers of Diagnostic Uncertainty

A. Compton Broders, MD, MMM - A Reflection

INTRODUCTION

Have you ever wondered if emergency medicine is the right specialty for your career?  …if you are a good emergency medicine clinician?  How do others cope with the unanswerable questions that you constantly face?  …How did they become the clinician that you want to be?  These answers are not in textbooks or journals.  You don’t learn them by shadowing or scribing for someone else. You can learn these truths through 40 years of introspective work in a busy ED.  Or, you have to get inside the mind of an experienced emergency physician who has already been there.

Luckily for you, Drs. Alex Koyfman and Brit Long have already done this for you.  They have collected and edited the musings and insights of a group of thoughtful emergency physicians.  They share their own fears, weaknesses, and uncertainty, but also tips on how to cope, to handle the enormous responsibility and the immense number of decisions that an emergency physician faces every shift.  It is not the many facts that you memorize and file away that will carry your day, it’s how you see yourself, how you shape your thinking and the attitude with how you carry yourself.  What makes a happy and successful emergency physician?  It’s the EM mindset.

- Louis Ling, MD

The good physician treats the disease; the great physician treats the patient who has the disease. - Sir William Osler

What mindset prevents early career burn-out? What tools elevate the provider to excellence in patient care? What inspires innovation and passion for teaching? What separates the good physician… from the great physician?

The EM Mindset is a collection of practice pearls revealed by contemporary physicians, walking in the footsteps of giants. From national legends Rob Orman, Salim Rezaie, Tim Horeczko, Anand Swaminathan, and many others, come secrets to balance a sustained and fulfilling career in emergency medicine with state of the art patient care.

This wisdom is not what we would expect. Far from the ‘sexy’ care of a multi-trauma victim, septic shock patient, or crashing asthmatic, are tips to approach the more mundane and repetitive aspects of our daily shifts; behave as you would like to be remembered, find your own route, run toward sick patients, be a role model, practice humility and kindness, and strive to be the shelter in your patient’s storm.

Drs. Alex Koyfman and Brit Long have collected a lifetime of insight, and share sage advice in this engaging new compilation. The reading is fast paced and colorful, with important lessons for the enthusiastic new graduate, for the jaded mid-career provider, and for the wizened emergency physician in the twilight of their career. The lessons are tangible, and strike to the core of how we balance caring for sick patients, while remaining true to ourselves and our families.

To quote one of the authors, our goal as physicians is To Safeguard, To Comfort, and To Guide. The lessons relayed in this book accomplish all three.

- Michael B. Weinstock, MD

This book of essays by leading thinkers, scholars, and educators in emergency medicine demonstrates how far the field has come in the past five decades. Emergency medicine has fueled the passions of some extraordinary doctors, who constantly strive to improve care and make us better teachers. As a deputized historian of the field, I am struck by the numbers and talents of emergency physicians who can write thoughtfully about their work. It wasn’t always that way.

The founders of emergency medicine practice, residencies, and our specialty board were a small band of brothers (with a few sisters) who spent almost all of their energy and time organizing, lobbying for, and creating the infrastructure so that emergency medicine would have a credible local and national base of operations. Not much was published at that time on the philosophy, scholarship, ethics, or aspirations of the field. Peter Rosen’s Biology of Emergency Medicine paper was the rare example of a scholarly essay that described the legitimacy of emergency medicine as a medical discipline.1 The small number of available leaders in emergency medicine in the 1970’s and early 1980’s meant that a few people did a lot of the work. Ronald Krome, for example, was the inaugural editor of Annals of Emergency Medicine but also served as President of University Association of Emergency Medicine (UAEM, the precursor of the Society of Academic Emergency Medicine), the American College of Emergency Physicians, and the American Board of Emergency Medicine – all within the time period of a few years. That has all changed now. 

In the past 30 years, emergency medicine has progressively attracted more and more high level scholars, academicians, researchers, and leaders. The expertise of our educators and investigators is on par with or better than other specialties. In addition to writing grants, publishing scientific manuscripts, and writing books, our emergency medicine leaders now have a few decades of perspectives and wisdom to put into the types of essays collected in this book. The insights, advice, and recommendations in this collection are a valuable state of discourse on key topics in emergency medicine. Emergency medicine has a rich history, but here you find the dynamic ideas that will take our field in to the future.

Rosen P: The biology of emergency medicine, JACEP 8:279-283, 1979.

- Brian J. Zink

ACKNOWLEDGEMENTS

This book is a brief insight into the minds of emergency medicine masters. Emergency medicine is a specialty with moments of joy, fear, sadness, elation, and trepidation, and we as EM physicians often meet patients in some of their most vulnerable moments. We thrive in resuscitation, quick thinking, emergent procedures, care coordination, and task switching, while caring for patients of all walks of life no matter the time of day or insurance status.

Emergency physicians are provided respect in today’s medical environment, but years ago this was not the case. The pioneers of emergency medicine, our founders, created a specialty that revolutionized emergency care for everyone. Thousands of amazing physicians have followed in their footsteps. This book would not be possible without the likes of Dr. Joe Lex, Dr. Peter Rosen, Dr. Judith Tintinalli, and many others. This book is partly a tribute to them, their efforts, and their careers.

It is our pleasure to bring this collection together, and we thank the authors involved in construction of this book. We also extend our gratitude to our families for their amazing support and patience during the writing and editing phases. Manpreet Singh, M.D., was one of the primary movers for this project, and this project comes from his masterful work. We also thank Dr. Broders for his grant, making this project possible. All of the emDocs.net team including Drs. Stephen Alerhand, Jennifer Robertson, Erica Simon, Jamie Santistevan, and Courtney Cassella played a significant role. We hope this collection provides insight into emergency medicine and its experts.

Alex Koyfman, MD ([email protected]) and Brit Long, MD ([email protected])

The Emergency Medicine Mindset

THINKING LIKE AN EMERGENCY PHYSICIAN

Author: Joe Lex, MD (Clinical Professor of Emergency Medicine (Retired), Temple University School of Medicine - @JoeLex5)

Emergency Medicine is the most interesting 15 minutes of every other specialty. – Dan Sandberg, BEEM Conference, 20141

Why are we different?  How do we differentiate ourselves from other specialties of medicine?  We work in a different environment in different hours and with different patients more than any other specialty.  Our motto is Anyone, anything, anytime.2

While other doctors dwell on the question, What does this patient have? (i.e., What’s the diagnosis?), emergency physicians are constantly thinking What does this patient need?3  Now?  In 5 minutes?  In two hours?"  Does this involve a different way of thinking?

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues.  Yes, we do it on a daily basis, many times during a shift.  Every time I introduce myself to a patient, I never know which direction things are going to head.  But I feel like I should give the following disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues.4,5 You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  After today, we will probably never see one another again.  This may turn out to be one of the worst days of your life;6 for me it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.

I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.7

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG.  I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.8

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up the odds are very, very good that you will be fine.  Voltaire told us back in the 18thcentury that The art of medicine consists of amusing the patient while nature cures the disease.  For the most part this has not changed.  In addition, Lewis Thomas wrote: The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.9  Remember, you don’t come to me with a diagnosis; you come to me with symptoms.

You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good.  You may have an uncommon presentation of a common disease, or a common presentation of an uncommon problem.  If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.10

The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.11

You may be disappointed that you are not being seen by a specialist.  Many people feel that when they have their heart attack, they should be cared for by a cardiologist.  So they think that the symptom of chest pain is their ticket to the heart specialist.  But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection?  So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical.  We are the specialty trained to think like this.12

If you insist asking What do I have, Doctor Lex? you may be disappointed when I tell you I don’t know, but it’s safe for you to go home without giving you a diagnosis – or without doing a single test.  I do know that if I give you a made-up diagnosis like gastritis or walking pneumonia, you will think the problem is solved and other doctors will anchor on that diagnosis and you may never get the right answers.13

Here’s some good news: we are probably both thinking of the worst-case scenario.  You get a headache and wonder Do I have a brain tumor?  You get some stomach pain and worry Is this cancer?  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word stroke or cancer, then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.14

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.15

I will use my knowledge and experience to come to the right decisions for you.  But I am biased, and knowledge of bias is not enough to change my bias.16 For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.17

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).18  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).19  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.20

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is essential for me to do so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.21

What’s that?  You say you don’t have insurance?  Well that’s okay too.  The US government has mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact I can be fined a hefty amount if I don’t.  And a 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.22

But you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracostomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter.  I can float your temporary pacemaker, I can get that pesky foreign body out of your