May 3rd, 2015

Thoughts on Residency–One Month After Graduation

By Jeff Wiswell, M.D.

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*For what it’s worth, these were my thoughts to my previous residency junior colleagues one month after I graduated two years ago and started an ultrasound fellowship, where I worked half time as an ED attending.

Just about any accredited program will provide solid training, but it’s very easy to skate by and let the system take over care of the patient.  Although this works, this method takes away from your education.  Not to sound intimidating, but after you leave residency, you likely won’t have the the same resources you have now, maybe more or maybe less; but you will have to adapt to it.

Given that, I’d implore each of you to push past your comfort zone and learn more than is required of you.  Learn how to interpret vent settings, put in NG tubes, reduce fractures, do regional anesthesia, etc.

So for some of the differences . . .

 

SYSTEM-LEVEL DIFFERENCES:

1) You may not have RT as readily to help with all sedations and may have to push your own meds--this was a big and scary change

-I made a big push to learn ultrasound-guided regional anesthesia for this reason

2) You won’t consistently have real-time radiology reads, especially overnight

3) If the nurses can’t get it and it’s needed, you better be good at putting in an ultrasound-guided IV or you’ll be doing a central line or IO 

- The EJ is an underutilized vein . . .

4) You likely won’t have access to all of the patient’s records anymore, since most cities have multiple hospitals on different systems (same goes for EKGs)

5) You may be boarding ICU patients (one shift, I had 8 of them . . . who were there for the entire shift ...)

6) You have to advocate for things you believe are right

7) The chest pain workup is no longer an easy pathway to 1) Admission or 2) the OBS unit, so you’ll have to figure out who you’re comfortable discharging home.

8) You don’t get much feedback anymore as an attending:

- I tried to call as many discharged patients as I could to make sure things were getting better

- Then I documented this call in the record

9) Supervising junior residents is difficult and has the potential for things to get missed.  Work on this during your final year.

10) Now you're responsible for seeing everybody

 

MEDICAL KNOWLEDGE/GENERAL PRACTICE:

1) You’re going to be expected to diagnose and treat things you’ve never seen, heard of, or taken care of before.

- This probably happens at least once per shift—in my first week in the pediatric ED, I had an 8 week old kid I sent home with fibromatosis colli of the sternocleidomastoid . . . (WTF...)

- My very first patient as an attending had secondary syphilis (I wore gloves).

-Number of syphilis patients I saw in residency: 0

2) You need to have enough medical knowledge so you can stay composed in the setting of multiple sick (and well patients) because people start looking at you now for answers:

- On the night shift before I wrote this, we had an (at the same time):

- Infant code

- Intubated peds trauma just arriving

- Critically ill dialysis patient with significant pulmonary edema on BiPap and no venous access

- Ongoing food bolus sedation (that I later needed to intubate & then extubate before sending home)

- Hypotensive stab wound to the chest

- Alcoholic with ascites, abdominal pain, and SBP

- About 15 people in the waiting room & a full ED

- At the same time, the in-between patients are the biggest diagnostic dilemmas and the ones you’ll spend the most time with and assume the most risk

3) You’re going to see a pregnant patient at least once per shift

4) Back pain is rampant and you need to be good at documenting well and picking the needle out of a haystack

5) You’re the emergency physician now.  If you don’t know lifesaving medications and doses instantly off the top of your head, patients may die.  No way to sugar coat this.

- To reiterate, it’s just unacceptable not to know the exact weight-based dose for RSI meds, sedation, asthma interventions, vent settings, ACLS/PALS drugs, pressors, IVF/Blood/FFP dosing, dextrose, narcan, hyperkalemic meds, nitro drips, ETT sizes and depths for kids, . . .

- Because physicians there pushed RSI drugs, I had to know the concentrations too

- Pocket cards are for the internist or pediatrician.  When a parent brings in a kid turning blue and you have 1 nurse, you don’t have time to read the pocket card . . .

- Online resources such as UpToDate are very appropriate for non-emergent diagnoses, drugs, and dosages

- To reiterate once again, your job is to treat life, limb, or eyesight threatening emergencies--memorize this stuff so that it’s “brainstem” information at 2 AM

6) You’re going to read about 10-15 EKGs per shift and nobody else will over-read them until maybe the next day

7) You need to know common eye complaints and emergencies: I had 3 slit-lamp exams my first shift in “Fast Track”

8) You need to be able to quickly and efficiently perform all procedures expected of an emergency physician.

- In my first week, I had to put in a dialysis catheter to emergently dialyze a hyperkalemic patient.  On my first peds shift, I had to intubate the 3rd kid of the night (combative, head injury) with about 50 people watching (med students, techs, trauma team, nursing, etc)

- If the resident can’t get a procedure, you need to get it or the patient may die (in some cases).  In addition, the procedure is now invariably more difficult . . .

9) You may not have any airway backup.  Besides another EM attending (which you may not even have), I didn’t readily have anesthesia available, so you have to be facile with a fiberoptic scope and a scalpel if need be.

- I would encourage you to try to get time in the bronchoscopy suite or at the very least use the NP scope to get a sense of the anatomy and the controls

- You also need to know appropriate topical anesthesia for the procedure (again, “Brainstem” info rather than looking it up or calling pharmacy).

- Even if you have anesthesia back-up, they may have 30-60 min to respond from home (i.e. much longer than the cerebral & metabolic effects of hypoxia)

10) You may not have psych, so you may have to medically clear/transfer or discharge home

11) One of the trauma surgeons told us during the first week of residency to “Load the boat (with consulting services/labs/imaging) because 'you don’t want to go down alone on a sinking ship'”

- She was very wise . . .

 

OVERALL:

- Read and learn as much as you can in residency--it’s shorter than you think and you’re now expected to know it, since you’re not the resident anymore. 

- Talk to the consulting services and ask questions about their management so that you can do it when you’re on your own if necessary

- I studied more after finishing training than I ever did as a resident (and I was somewhat of a nerd . . . ).

- You’re now an adult-learner, so develop a system and resource network to continue learning.

- Find podcasts, blogs, article libraries, evidence based guidelines, expert reviews, etc.

- If you ever get stuck, think about what the best attendings in your residency would do . . .

- Billing and coding is important.  We had some experience, but you need more.  Look for podcasts and PDFs by Michael Granovsky (EM doc and ACEP billing guru)

 

Again, you all get great training, but you really have to maximize it for your own benefit.  

- Seek out unique experiences & sign up for chief complaints that you’re uncomfortable working up before you finish training

- Do procedures early & often so you can see all the nuances and potential complications that may arise and ways to work around them.  Be selfish about getting abundant procedural experience

- Ask as many questions as you can.  Then ask the same question to multiple different consultants for a unique perspective

- Try different approaches to the same problem while you have the time to practice under direct supervision

- Always be confident but humble.  The minute you think you’ve mastered it or become too smart for this job is the minute you’ll get burned. 

 

 

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