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…
**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:
#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.