Author: Eric T. Boie, M.D. Assistant Professor Emergency Medicine. Mayo Clinic.

First impressions are very important, and can doom you or poison working relationships for quite a period of time.  For this reason, prudence dictates thought before action, and careful investigation of what underlies a problem.

#1 ESTABLISH KEY RELATIONSHIPS

You should take the time to meet with several key players.  For many, this will be the first time that an EM physician has done so.  I have received feedback from several of our graduates that have done this that they feel it paid tremendous dividends.  You be the judge…

•  Medical Director:  (your boss).  Be certain that you have no further questions about your contract.  Assure that the orientation period is reasonable.  Ask under what circumstances they would want you to call them at home about a problem during a shift.  Be certain that you understand how the arbitration system works when you disagree with a consultant.  Clarify transfer policies, psychiatric case treatment plans, floor coverage during the time of a busy shift and order writing.  Clarify what your GOALS are for the upcoming year.  Have a list of your own in case your director doesn’t have any.  Be certain to include time needed for ABEM prep and testing.  Ask what the sick call protocol is… for instance frame questions as “what if I get a call from my relief saying that they are too ill to work”?
• Nurse Manager of the ED:  Often the second most powerful individual within your workplace.  Don’t get off to a bad start.  Find out what their (nursing’s) perspective is about EM, the ED and the hospital.  What are their expectations of you?  How would they like you to handle praise for a nurse (this one usually knocks them over…a doctor looking for ways to praise a nurse!)?  How should disputes with a nurse be handled?  Would it be OK for you to check back in a few weeks for some feedback?
• Hospital CEO:  A quick, 15 minute session to introduce yourself and find out what their vision is for EM at the hospital.  Do they have any specific concerns about the ED?  What aspects are they most proud of (hospital and ED)?
• Medical Staff President:  15 minutes (in some hospitals this may become a breakfast or lunch meeting).  Again, a simple introduction and query about strengths/weaknesses of the hospital and the ED.  You may wish to broach the hypothetical situation of a consultant who is impaired at this meeting, or what to do if you strongly disagree with a consultant’s recommended plan.
• Department/Section chairs for the major clinical patients that you deal with.  A short sweet, strengths and challenges type meeting.  In addition, find out what they would recommend that you do in the “hypothetical” situation of one of their on call colleagues that refuses to see a patient, or if you have a disagreement over management.
• Other key people may include the EMS director (medic praise or concerns, protocols for your county), social work director or chaplaincy representative for the ED.

**Meet with both the medical director and the nursing manager after about 7 and 30 shifts to get their feedback about your performance.  This affords an opportunity to correct any misperceptions about you that may have developed.  Ask for honesty

#2  BE PREPARED CLINICALLY

Before your first shift:

• Familiarize yourself with the airway kits & materials (adult & pediatrics).  Be prepared for a less sophisticated “difficult airway kit” than you’ve come to expect.  Do they have intubating LMAs?  Gum elastic bougie?  Glidescope?
• Review location of code equipment (IO lines, E-Z IO, chest tubes, central lines)
• Review protocols (e.g. for conscious sedation, infiltrative anesthesia, NG  tubes & foleys, wound cleansing).
• Review referral patterns for things that “cross” boundaries, and how the primary care doctor influences such decisions (back pain, GI bleeding, hand injuries, facial injuries and foot problems).  Who does surgical subspecialty work such as “plastics”?
• All set to do a precipitous delivery?  The nurses will be impressed that you asked.  Know where to locate the equipment too.
• Review limitations on the availability of diagnostic tests (US, MRI,  Dopplers).  How do you get an expedited wet reading, or what do you do if you have questions about a remotely generated reading?  Are patients ever transferred due to the lack of availability of a consultant or diagnostic study?
• The “Discrepancy/Culture Log”.  Are you responsible for contacting patients with radiograph discrepancies or positive cultures?  If so, how do you document those activities?
• Review the base station protocols for ambulances (so you don’t embarrass yourself asking for something that they don’t have).  Do the nurses or do you speak on the radio?  There will be a wide array of differing practice patterns … no IV pain meds w/o order, routine use of pre-hospital 12 lead EKGs, formal reporting of stroke scales, etc.
• References and resources (social work, legal, chaplaincy) available to you in the ED.
• Clarify responsibilities that may exist outside of the ED … when should you respond to a code?  Do you cover ICU pts?  L&D?  What if the EDs busy with volume?  What if you have a really sick pt. and are called to one of these??

 #3  KEEP EYES OPEN, MOUTH SHUT

Don’t say “At my old hospital, we would do.....”.  You aren’t at in your residency any more, so instead adapt ideas or concepts that did well here to your local environment.  Don’t try to change a guideline in the middle of a shift.  There must be buy in from the nursing and physician management, and sometimes from the medical staff itself.  If this is an issue worthy of “falling on your sword over” (e.g. the patient’s welfare is compromised), do it yourself, or tactfully beg the nurses to do it with a promise to fully explain later.  More likely this is a “style” issue, and better worked out at a later time.  This IS different from teaching providers during your shift (that’s always appreciated).

 #4 LISTEN AND LEARN

Ask for advice liberally, and listen to it in a non-judgmental fashion.  Use actual questions that pop up during your shift to ask more “hypothetical” questions about admitting strategies, referrals, transfers, etc.  Above all, don’t be afraid to say “I don’t know, can you help me”?.  While you are expected to be well trained, your group should also understand that you lack experience (remember that it takes 7 years to become an expert…those 40,000 patient encounters).  Also, nobody likes a “know-it-all”.  Caveat:  don’t play “dumb” as that’s not respected by nurses.  Instead play “receptive” to learning how they approach a problem.

#5  BE EXTRA NICE – JUST LIKE KINDERGARTEN

Be generous with your appreciation and manners.  Give people the benefit of the doubt, and say “Thanks” a lot.  Compliment people on their work.  After your first critically ill patient or code, take a few minutes to reassemble the team and praise them for their work (dwell on the behaviors that you thought were good).  Caveat:  Nurses expect you to be decisive and to lead a code or management of a critically ill patient.  Ask for input and ideas as you do this, but be a leader.  Over the years there’s been an impressive litany of challenging “1st shift” pts – 2 week old congenital heart, precip delivery, multiple trauma simultaneous arrival, etc.

#6 TIMELINESS IS NEXT TO GODLINESS

 Be on time -  even a few minutes early, for your shifts.  Dress professionally and take the lead from others that you work with.  Stay over at the end of shift to tie up loose ends.  And DO NOT be the doctor that everyone hates to follow because the WR is bursting at the seams or your patients are only half dispositioned.  Make yourself indispensable to your new group, and a favorite amongst your partners and nurses.

#7 PATIENCE IS A VIRTUE

Be PATIENT for your first 6 months.  Again, anyone can identify a problem...the challenge lies in finding the correct solutions for the local system.  Don’t make waves early!  Study the problem, research possible solutions and present them...or volunteer to work with a group of people that are tasked with finding a solution.  Presenting problems to the director without recommendations is usually perceived as whining.  It takes a while to learn the local politics and history of the institution…both strongly impact operations.  Chances are, if there was a simple solution, it would already have been solved.

 #8 FACTIONS WILL FRACTURE

 Avoid being pressed into “taking sides” in disputes that have a history and growth that predates you.  It may take over a year to sort through these.  Politely explain that you don’t have enough background information to make a judgment on the issue.

 #9 WIN OVER NURSING STAFF

Ask the nurses for their perception about consultants prior to placing the call....may help you better prepare for a “crusty” consultant, or understand their treatment preferences.  Again, making a good first impression with these consultants can pay dividends.

Check the work of the nurses (e.g. wound cleansing, splint application, discharge instruction).  If you identify concerns, try to decide if it’s a systems problem (need for education, understaffing, etc.) or an individual nurse problem.  System concerns should be brought to your boss.  Be prepared to offer your services to solve the issue (e.g. put together an in-service for the nurses).

 #10 USE EVIDENCE FOR CHANGE

Use the medical literature to support recommended changes in practice patterns.  This is true for the nurses and physicians.  This becomes less threatening, and allows the transition to an “EBM” ED to begin.  Be tactful in this however….don’t come across as righteous, but instead humble.  “This is an article that caused me to rethink how I approach this diagnosis…”.  Doing this for the nurses and EMT-P’s also comes across as caring about them as team members.

ONE EXTRA: MAKE NEW FRIENDS….BUT KEEP THE OLD

For those going to a solo practice environment, the biggest adjustment is how lonely it is there.  You may wish to exchange work schedules with your classmates along with work telephone numbers.  On a slow night shift you can catch up with a peer who is also working nights, or ask for that second opinion.  And don’t forget, the “Mother Ships” are always open and we’ll be happy to serve as an informal second opinion for you.

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