Author: Andrew Sloas, DO, RDMS, FACEP, FAAEM (Assistant Professor of Adult and Pediatric Emergency Medicine, The University of Kentucky; Editor-in-Chief: The PEM ED Podcast (www.pemed.org) – @PEMEDpodcast) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)
What makes the practice of emergency medicine special? Why are we so different from the myriad of other providers that it is imperative we have our own subspecialty? It’s not like we have an –OLOGIST at the end of our name; those seven all-important letters designating to all they encounter that this doctor has a depth of knowledge about their specialty that exceeds all others. How would the -ologist define our specialty? I suppose it would start with what we do best; we are the masters of the differential diagnosis. To be a successful emergentologist, one must possess a depth of knowledge about physiology, critical care, and procedures that exceeds all other subspecialties. We must have it all or patients die!
We are a life and death subspecialty. While most may argue that cardiology is the best doctor for the heart and anesthesia is the best doctor to manage the difficult airway, I would dissent. An emergentologist does not have the luxury of meeting their patients in a clinic where they can casually sip coffee as the patient provides a thorough and detailed history. In fact, with the sickest of patients in the emergency room it is often the exact opposite. As an emergentologist, you will be asked to make life and death decisions with less than 10% of the total information 99% of the time. If you fancy yourself a rebel and that gives you absolutely no pause then consider this: you will be asked to get it right every time or it could cost the patient their life. That is a tremendous amount of pressure once realized and usually not in the forethought of those considering a career in emergency medicine.
While many subspecialties lend themselves to a culture of relaxation, a career in emergency medicine cannot be a lifestyle choice. If the anesthesiologist does not like the look of an airway, much like a pilot who decides they don’t like the weather conditions, that flight/case is canceled. That case is then rescheduled with a plan, a back-up plan, and a redundancy plan to successfully intubate that patient. In the emergency department you do not get that option. You don’t get to look at the patient with hepatitis C, and an active GI bleed and say, “I’m not feeling it today, sir. Perhaps you’d like to reschedule on a day that someone who’s infinitely better at difficult airways is here.” You, as an emergentologist, get to meet the bloodiest most vomit-laden airways in the world whenever they choose to meet you. Now here is what is truly unfair; when we struggle with the difficult airway someone may ask, “do you want me to call anesthesia.” Why? Because they are viewed as the airway experts and you are the novice. They are the masters and you are guy or gal who’s good enough to do the basic ones, but because they have an -ologist behind their name they must be technically better than you could ever be. Is that true? We just established that they have the ability to plan their cases on the golf course the day before or, at worst, over coffee in the hospital atrium that morning. Either way, the plan is in place long before they have to cross the threshold of commitment to paralyze and take the airway; a luxury you don’t have. As an emergentologist you are also a vomitologist. Vomit happens in real time, not over coffee before you meet the patient. For that reason, it is my propensity to believe that the emergentologist is the absolute best practitioner to manage the most difficult airways.
But what truly makes the practice of emergency medicine different is our innate ability to recognize sick from not-sick. If you go into this specialty under the guise that you will someday be a master diagnostician then you will be sorely disappointed and that disappointment will likely spiral into despair as you burn out in a matter of years. That is not our lot. Our responsibility is to be excellent differential diagnosticians not definitive diagnosticians because ours is a specialty of recognizing the sick. Like a goalie, we prevent those in extremis from slipping by while simultaneously redirecting all others to continue their “medical” fight another day. Not every disease needs to be diagnosed in the emergency department. It is your job to figure out which ones do and which ones are safe to go home. It has been said that a good emergentologist can make the diagnosis of sick–not–sick in three seconds from the bedside and in thirty seconds form the doorway. This skill must be developed for you to be successful in this business; this must be your overall mindset. You must be able to differentiate quickly, rule out the worst-first in disease processes, and use a series of complex hierarchical algorithms to determine how sensitive you will be when your tests return. Pre- and post-test probability rule the day and utilizing gestalt combined with concomitant data points such as labs and rads is the only way to develop the confidence to decisively send patients home to do well… and not lose any sleep. Easy right?
In the emergency department you are only as good as your last case; ‘tis the standard by which you will be weighed, measured, and found wanting… or in the best possible scenario, given some type of wall trophy. You may be the brightest differential diagnostician, most handsome emergentologist, or beautiful resuscitationist to ever grace the face of this earth, but you mess up one case… you may have placed three chest tubes, intubated the last five patients fiber-optically, cracked two chests using only one hand all the while simultaneously seeing the other fifty cough and colds that came into your department, but if you miss one MI in a ten-year period you are “just another bad ER doc.” While successful diagnosis and treatment in the face of minimal clinical information involving the sickest patients is the norm, perfection is the standard by which you will be judged and as we are a life or death specialty the expectations set by your colleagues/consultants are high. While the consultant may often forget the luxury of her controlled clinic environment, I must agree with their mantra. If you choose this specialty, it becomes your responsibility to accept the limitations of the practice of emergentology and do everything possible to safeguard your patient and yourself against disaster. For that reason, the emergentologist must be the most well-rounded and well-read physician in the hospital. Do not rely on your residency program alone for your training; there is no excuse for that in this day and age. To quote Dr. Stuart Swadron (USC-LAC), “the expectation for the emergentologist these days, is that as ER physicians we need to know our job plus one step more.” What Dr. Swadron means by “one step more,” is that to successfully take care of the most critically ill patients in the emergency department we must know the first, second, and sometimes even the third steps our consultants would have performed if they were in the emergency department to assume care. Why? Because as our knowledge and skill set has increased we have outgrown the basic services our consultants used to provide for us. We have become so self sufficient that the consultants have become reliant on us to take on a much more integral role in the care of the critically ill. The more adept we become, the more they expect. The more they expect the more we end up doing and the more we end up doing the less we find the consultants in proximity to help us out. For that reason, we need to know what used to be “our job,” but now we also need to know a decent part of our consultant’s specialty. It’s a double-edge sword. We have become sufficient and they have become reliant.
Do not get me wrong we need consultants now as much as ever, but we must realize that our consultants wear blinders. When we call them with a specific question they’re extremely versatile at answering that question, however if we have asked them the wrong question we invariably get the wrong answer. When you call a neurologist for a question about stroke they will undoubtedly be able to answer your question in a succinct and timely manner. They will offer you therapy suggestions and guide you towards treatment protocols, however if your initial diagnosis was incorrect then all of the CVA guidance in the world will not fix the patient’s temporal arteritis. So I ask you, is it their responsibility to help you make that diagnosis? The consultant is only as good as the question you asked them and they do not keep a wide differential of other potential disease processes like you must. You are the goalie! You are the differential diagnostician! While you must value and rely on your consultants for direction in disease processes that they have primary knowledge of, you must also be the gatekeeper. You must decide when their recommendation does not fit with the current treatment strategy and you must be responsible for constantly re-evaluating all of the data to make sure that the working diagnosis is still the most likely diagnosis. Your consultant will not usually help you in that arena. That is what you have been trained to do, you are the differential diagnostician and you are required to be the supreme manager of the care of your patient.
Far too often I see colleagues say “well that one is already admitted to medicine, it’s their responsibility.” That my friends, is the ultimate cop out. You did not take an oath to take care of patients from the moment they entered your emergency department until the time you signed an admission order. You took an oath to take care of patients no matter what the obstacles; no matter if your shift is about to end, no matter whether or not you like them as a person, and no matter what friction it causes with hospital administration. Your oath entails that you put your patients before yourself, your feelings, your biases, and your financial motivations. While, “they can’t stop the clock” the physician that leaves on the hour that he is scheduled and does not stay to take care of the sickest of patients that needs his or her services should have his privilege to practice emergency medicine revoked. Don’t get me wrong the shift is part of the perk of emergency medicine, but your oath says nothing about the shift. The sickest of patients need you and that is your ultimate responsibility and that is what you signed up for. The same holds true for difficult administrators and consultants. It is unfortunate that in this day and age a “patient centered care” approach to practicing medicine has been abandoned for throughput times, black ink over red ink on a quarterly statement, and quality sacrificed for speed. We have all had to deal with those consultants and administrators that subscribe to these aforementioned philosophies, but it is unacceptable to buy into that as an emergency physician. You must be the supreme advocate for your patients because you have the widest vantage point, which allows you and only you, to practice without blinders. If you do not take responsibility as the primary patient advocate then assume that no one else will. This part of our profession is probably the hardest to accomplish in a manner that protects your patients while simultaneously steers clear of offending those that you rely on to help you provide the care your patients require. It is a skill that few possess, less utilize, and even fewer know how to obtain. My advice, as soon as you identify someone with a proficiency in the art of interfacing with administrators and consultants try to learn everything you can from them and request they mentor you.
An emergentologist is not a doctor to the stars, but a doctor to the working class. You will not be laden with jewels, compliments, and presents at Christmas but the gift you will receive is far more valuable. The profession that you have chosen allows you the opportunity to save a life on a daily basis. If that is not the most fulfilling thing you have read than it might be a good time to start looking into other specialties. While we have established that your consultants will hold you to an unobtainable standard and that if you are really exceptional at this job you will hold yourself to an even higher standard, but the patient holds you to the simple measure. They expect you to be capable to help them in the time of utmost need. That being said, you must understand who your patients are and what they need from you. While as emergentologists we do suffer the plight of interacting with malingerers and drug seekers, if you choose to concentrate on that population you will have a short and bitter career. I encourage you to take quite the opposite approach. Concentrate on those that come to you scared, sick, and in need of treatment. Your patients, as a whole, will have very little preceding medical background. Their ignorance of medical practice may generate questions which may seem mundane or even elementary to you, but I highly encourage you to check that attitude. The mother of the two year-old child with a headache is concerned that her baby has a brain tumor. You know that ninety-nine percent of the time it is not a brain tumor, but I encourage you to find your humanity and innermost compassion to interact with that mother like she was your own wife and this was your child… because someday it could very well be.
I believe that may emergency physicians feel they can have a successful career and protect themselves from burnout by developing an emotionless stonewall approach to patient disease. In reality that may be the furthest thing from the truth. Empathy and compassion should be the cornerstone of your care. When a patient receives the news that they have “just been diagnosed with cancer,” they are devastated. Whether it be in a patient with no preceding medical education or a physician who receives the diagnosis, those words strike terror to the core of the recipient. I am not sure at that point which would be more equipped to take the news, the physician who already has calculated the odds of survival and fast-forwarded through the treatment options before the doctor has finished delivering his monologue or the teenager who has no understanding of what a chemotherapy regimen is, but both will suffer the same in time. They will not remember the specifics of what you said when you turned their life upside down, but they will absolutely remember the fact that you sat with them for ten minutes cried, empathized, and answered all of their questions. While that does nothing to cure them physically it absolutely heals them emotionally and I believe you will find that the more you connect on that level with your patients it will heal you as well. Our job is fantastic, but we see the worst of the worst. We see the most horrible possible tragedies. We see drunk drivers devastate families; families that are left to pick up the pieces of missing spouses and children. We bear witness to patients that believe they’re perfectly healthy when they enter your department only to be given a new diagnosis of malignancy. We are forced to look for innocent battered children hidden amongst the piles of routine trauma. Practicing in that type of environment takes its toll on you no matter who you are. If you ignore that it exists these demons will overwhelm you as they have overwhelmed your predecessors; the end result will be your own demise/burnout. It is my opinion that the purest form of catharsis occurs when you can connect with the patients and families when tragedy strikes. Blinding an eye will callous your mind and the calloused mind is not long for this profession.
To be truly gifted at emergentology you must become an emergency medicine sensei. A master of your art, skill, and craft. While many disciplines of martial arts use secondary weapons to achieve victory, none rely on those weapons primarily. While laboratories, radiographs, and the myriad of other supporting tests at our disposal may be useful to a Master of Emergentology, they should be viewed as no more than secondary weapons. The mind is the primary weapon of the Emergency Medicine Sensei. A master practices emergency medicine artfully; utilizing history-taking and physical exam skills first. Labs and rads are secondary weapons and should only be employed selectively when needed to confirm what is already known. Tests should not be used as bait, shotguns, or pixies that we can attach wishes to for a “correct diagnosis.” Last time I checked, there was no shotgun training belt in the martial arts. Do not get me wrong, many patients need radiographs and laboratories but they should only be used to support your current working differential diagnosis not to develop one. More importantly, when those tests do not support the diagnosis, then the emergentologist must realize that the working diagnosis must be changed or the laboratory data is erroneous. To rely on labs and rads to help you make a diagnosis as opposed to ruling in or out diagnosis is absolutely unacceptable. It puts the provider at risk of making both type one and two errors and more importantly allows the physician to send those home who should be hospitalized and admit patients that could be home comfortably sleeping in their own beds.
Unfortunately, many residency programs in the United States still subscribe to teaching the method of baiting and fishing for diagnosis over the systematic formation of pretest probabilities and confirmation of disease. Besides the fact that it promotes wasteful testing and increases work-up times, this practice style debases the level of thinking needed to be successful in our subspecialty. Plainly said, it produces substandard emergentologists. Greg Henry once said, “the WBC is the last bastion of the clinically inept.” This is one of the most profound things I’ve heard spat forth from a physician of any type and it was said by an emergentologist. An emergentologist, a doctor that has to put so much together with so little information, was the first to say that I’d rather have no test than a useless one. An emergentologist, beat all of the others to the punch and said that testing in this manner, testing for the sake of testing, is more dangerous than not testing at all. We have all been asked by our colleagues, “yes, but what was the white count?” Well, my belief is that you should not only be the first to say to your colleague “why do I care,” but more importantly recognize that the person asking you the question practices with bait and shotguns and their counsel is somewhat questionable given that statement. Dr. Henry eloquently summarizes that the emergentologist not only needs to be aware of the utility of the test they order, but must understand when the test is indicated so that it can be useful. It is also equally imperative to possess an understanding of when the test is likely to have such poor sensitivity or specificity that it could actually be detrimental to the workup by muddying the waters in an already complicated patient.
My sensei, Dr. Yash Chathampally, taught me to “beat the history bushes into kindling.” What that means is that success starts from the outset with the best possible history and physical exam. History may be limited with our sickest patients, but every ounce of supporting data you can acquire from the encounter may be the difference between a usable differential diagnosis and certain patient demise. It is in this forum where the student becomes the master. The learner must steer away from anchoring and other biases that prevent adequate reevaluation of the data being accumulated. Laziness has no place in this venue. Early in their training, I have witnessed many residents in emergentology base an entire work-up on a single spurious data point. Even after the rest of their history and exam findings pointed to something entirely different. When I see this becoming a problem with a particular resident, I repeat the case back to them exactly as they have stated it, but leaving out what I suspect to be the one rogue data point. There are usually two possible responses at this point. The resident either says, “yeah, but that’s what the patient said happened.” Unfortunately, that is the more common response and the one that demonstrates upbringing in a system that has failed. The resident is no longer able to distinguish between fact and fiction; their filter is warped or altogether broken. What I hope for is the second type of response, “ah, I see it. I thought everything seemed right, but that part just didn’t make sense.” That is both a resident and residency program for which there is hope because the “spidey-sense” has not been extinguished. We must approach every shred of evidence acquired in the emergency room by applying pre-test probability, post-test probability, and Occam’s razor. In Occam’s Law of Parsimony, it is stated that plurality should not be posited without necessity. In other words, two pieces of data should not be connected without certainty that they are associated. This is quite possibly the single largest Achilles heel to the emergentologist. The path of least resistance is to blindly accept what the patient tells you because you want it to fit into your world view; you want it to be prepackaged and easy. After all, there are fifty other patients waiting to see you and there is no time for complication. “Of course you don’t have any chest pain Mr. Jones”, but is that what Mr. Jones said, or is that what you wanted to hear? Better yet, did your bias confirm it before you even asked Mr. Jones the question? Patients do not intentionally lie (most of the time) and they do not understand how to take all of their symptoms and put them into a logical order for you to make their diagnosis for them, but that is most definitely your job. To be a sensei you must develop the bedside acumen to question like a lawyer, listen like a judge, and discern probability like a mathematician. You must trust your patient, but verify the facts when things do not add up. If the facts do not fit your world view, ask more questions do not leave those stones unturned. To be a facile emergentologist you must be able to separate data from all of the black pearls that the patient will produce in their effort to be complete. You must support your differential with certain aspects of their story and leave the parts that don’t fit on the cutting room floor. You must also have the wherewithal to remember those facts because as the complex cases evolve, the data left on the cutting room floor may need to be examined, picked up, and re-spliced in to make this a box office smash as opposed to a “B movie” flop. Those that cannot process information in that manner are doomed to have a highly unsatisfactory medico-legal laden career in emergentology.
No matter where we practice, emergency departments are extremely busy. The expectation these days is to see more patients in a shift than is humanly possible, carve out enough time for the sickest patients, and meet the industry standard of perfection. Allowing the most critically ill patient to receive the wrong diagnosis or obtain the wrong treatment is completely on you. To prevent those negative outcomes it is extremely important to practice the philosophy, “it takes three to make a thing go right.” You might think that the three things I am about to speak of would be rooted in quality initiatives or safety measures and in a way they are; the three things that make a patient encounter go right every time are a really good primary, secondary, and tertiary exam. Of course, the obvious splinter in the finger can be removed without a re-eval, but for all of those patients with undifferentiated disease you owe it to the patient to reevaluate and re-collect more data at least three times. If your work-up does not support the working diagnosis then re-evaluate the patient and re-invent the diagnosis. This is extremely labor-intensive and with the ADHD personalities that gravitate towards emergentology, it can be an uncomfortable way to practice. Overcome it! Mentally think to yourself, I need to slow down with this one and get more data. I cannot overemphasize enough that changing your mentality and approach here will save you multiple meetings at a future time and place of your administrators choosing with angry consultants and plaintiffs’ attorneys.
Perhaps the greatest contribution to the practice of emergency medicine in the last ten years has been ultrasound. There have been numerous advances in technology and reductions in cost, which have allowed point of care ultrasound to land in your emergency department and nowhere else in the hospital could this revolution have had a greater impact. As we have already stated, we meet patients on their worst possible day. We are required and expected to come up with an accurate differential diagnosis in the face of what is, at best, a rudimentary history to support our working diagnosis. Point of care ultrasound allows the emergentologist to perform an accurate internal exam to complement their often cursory external physical exam. Exams like the RUSH can put to rest undifferentiated hypotension, the FAST can diagnose hemoperitoneum in less than 30 seconds, and Echo can find a pulse where there is none. Of course, there’s also no longer such thing as difficult IV access, a need to guess between abscess and cellulitis, and which patients with round bellies and no prenatal care are pregnant. Whether you like the idea of ultrasound or not it’s time to embrace it. Given our access to this device and its’ unquestioned utility in the ED, the expectations of those who grant your privileges are increasing and it is something that you will be required to learn. Your board will require you to know it, your administrators will require you to know it, the lawyers will require you to know it, and most importantly, your patients will be reliant on you to understand it. If you don’t like the idea of being the definitive decision maker on routine exams that’s fine; for those cases have radiology confirm your studies. I assure that this is not rocket science and something you can get very good at with very little practice. After all, it is significantly easier than most of the procedures we do in the emergency department. If none of those reasons seem worthwhile then consider that utilizing ultrasound routinely may have the greatest impact on how you narrow a differential diagnosis in patients with undifferentiated disease. It will not only make you faster as a clinician, but improve your throughput times and patient satisfaction scores. When a patient sees that you have taken the time to do an ultrasound on them while explaining how it relates to what you have found on your physical exam they will feel like they have had a more complete and thorough experience, whether that be true or not. I sometimes refer to it as a laser light show because it makes the patients feel so much better that they can actually see your line of thinking on a video monitor. Most importantly, ultrasound will allow you to pick up things that were not in your original differential and improve the overall care you deliver to your patients.
I alluded to this earlier, but would like to expand on the point now: if you are just entering this subspecialty or new to the game then you have been inadequately educated. Joe Lex and Greg Henry have both made the statement at different times, “if I want to know what was going on ten years ago I’ll read a textbook, if I want to know what was cutting-edge five years ago I’ll read a journal, but if I want to know what’s the most up-to-date way to practice right now then I choose FOAM.” FOAM is free open access Meducation or Medical Education. It is made up of a conglomerate of free/paid medical websites and podcasts that are updated in real-time. This open access medical education is then circulated on the Internet which is most accessible through iTunes. Who is behind the movement? People that feel so passionate about patient-centered care and medical education that they are willing to dedicate their own time and money to host these projects for your benefit. Yes, there are many FOAM choices out there but they follow the free market philosophy: only the best survive. When the market provides choice those that are inadequate or inaccurate quickly fall by the wayside. Critical care and emergency medicine are leading the way on this front. The quality is tremendous and it is the best possible way to stay up-to-date in our specialty. When patients seek your advice they are expecting and deserve the most up-to-date choices for their care. If your knowledge is five to ten years out of date that type of care is impossible to deliver. If that statement distresses you because you chose emergency medicine based on the fact that it was a three-year residency that would allow you to punch a shift clock after training was completed, while in the back of your mind your expectation was that the last day of residency would be the last day of learning, than I say to you, “get out!” There is still time to train in one of the other various subspecialties that require a less labor intensive approach to continuing education. Of course, you don’t have to get out, but if that is how you choose to practice you will undoubtedly answer to a lawyer, administrator, and eventually your creator for allowing apathy to affect patient care. There is no room for that type of provider in emergency medicine today. If you are shortsighted, you may view what I have just said as a curse to how you must organize your time and revamp your priorities, but that is not necessarily true. Everyone in emergency medicine can be a fantastic provider. If you’re honest with yourself and you have been practicing for a while then you know life happens. Keeping up with reading in journals is difficult. FOAM actually provides a much easier way to accomplish this obligation. Everyone has errands to run and dead time in their life. Start filling that time such as commutes, workouts/fitness, and errand running by placing a few podcasts on your smart phone and popping in your earbuds. Just a couple of podcasts a week will make you a better and more astute doctor. If you are a resident in emergency medicine, a couple of podcasts a week could turn you into the superstar of your residency.
The last and perhaps most critical point to live by is that both Press Ganey and crack kill. Don’t believe me? Before you decide, at least take the time to read this article published in March 2012 in the Journal of the American Medical Association. While many have said that we are in a customer service industry I would remind everyone that the goal of a business in a “customer based industry” is to separate the customer from their wallet. There is no CEO in the world that would be allowed to keep their job by giving away the service they are employed to market. We need to see our patients as what they are: people with little medical knowledge that are hurting, scared, and seeking our help. That makes them vulnerable and reliant on us to make maternalistic/paternalistic choices for them and that is a tremendous amount of responsibility. While many of our patients can participate in informed decision making, at the end of the day it was you who went to medical school and you who will have to potentially make that life-or-death decision for them. There is no other job that I can think of that comes with that type of responsibility. It is also my belief that one cannot serve two masters and if we start to view our patients as customers then one day we may also be asked to make that choice between their money and their wellbeing. What will you choose? To truly have a patient centered care environment the patient’s needs must always come first. Even before the money! You may say that will never happen where I work, but consider this: how many patients can’t get beds at private hospitals because they don’t have the right insurance, how many private groups refuse to admit patients for insurance reasons, and better yet, how many patients are discharged to seek care at “county” once their condition stabilizes. Now I’m not a zealot and if hospitals don’t make a profit than I understand doors close, but there must be some separation of church and state. Leave the money to the administrators and you, as the physician, concentrate on the patient centered care. The first time you choose the money over the patient is a slippery slope and that slip is hard to recover from.
Emergency medicine in my opinion is by far and hands-down the best profession in the world. As an emergentologist, I am allowed to care for the sickest of sick, save lives daily, work a shift without having to worry about a call schedule, meet some of the most interesting patients and physicians in the world, and I get paid to do it. That is a privilege and not a right and I am humbled to have been granted that opportunity. I also recognize that with that paycheck comes a tremendous amount of responsibility, perhaps more so than most other subspecialties as we are a life or death profession. I ask you to consider that last sentence when you find yourself leaning towards accepting insufficient data from a patient in lieu of asking a few more questions, when you search your soul and come to the understanding you need to find a way to become more adept at ultrasound, and when once or twice a week you turn off the music in your car and turn on the FOAM. These small lifestyle changes will increase your patient and personal satisfaction on a daily basis and make you the most fulfilled emergency medicine physician in your group.
This manuscript, like so many other ideas in emergency medicine, was inspired by Dr. Jerry Hoffman. The quintessential emergentologist and creator of the concept. Thank you Dr. Hoffman for all that you have contributed to Emergency Medicine.
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