How long did it take you?

[SERENITY NOW]

Hi everyone,

I am a new grad that started my first job in emergency medicine about a month ago.  I am very lucky in that they have very little expectations for me at this time.  Still, I have been struggling to get up to speed with some of the more practical aspects of practicing medicine:

 

-maneuvering a complicated EMR that is completely foreign to me.

-the somewhat convoluted process of admitting and discharging patients.

-***calling consults, presenting efficiently and having a sense of what exactly I need from consultants.

-effectively/efficiently writing the MDM.

-the "random" processes you just have to know, like how to involuntarily hold for suicidal ideation.  There seem to be a million random things to know!

 

There is so much to learn to be able to practice medicine that extends beyond the textbook/clinical skills and it seems overwhelming at the start. These are all things that I never truly learned in PA school because we weren't legally allowed to do many things, and now that I've started my first position I find it very challenging/stressful to figure all of this stuff out.  I understand it is probably something we all go through and will get better with time; I was just hoping to hear about other people's experiences...

 

So my questions are:

How long did it take you all to get a decent grasp of these practical aspects of practicing medicine? 

Do you have any advice for new grads to speed up this painful process?  Advice in general?  Advice specific to each bullet point above?

 

 

[RealityCheck]

Have you even looked at ICD10 yet?

 

Just kidding!

 

Welcome to the world of medicine!!!

 

1. A good practice will have super-users or trainers available for EMR usage. Especially if this is how meaningful use is attained or billing improved. There should be someone "at your elbow" while you navigate a chart and help you with smartphrases, fast moves and even templates if you like those (I don't). Ask your practice manager or the hospital IT dept to provide you with on-site - real time training so your time is used effectively and efficiently or you will struggle forever. There is no excuse for not having proper training or saying "oh, you will figure it out". Those don't fly.

 

2. Contact your local Mental Health Providers (county, regional health district, whatever is in your area) and have them meet with you. Ask for help on mental health and how-to? It varies city to city and county to county. You might even have to ask law enforcement about it. Write your own cheat sheets, laminate, whatever. There is no one bible for this and it is extremely emotional and difficult. Your hospital social worker might be a good resource. You will have to do this all on your own and show initiative. You will also learn to do it right and legally.

 

3. No clue on the admit question as the physician or hospitalist or whomever is admitting usually handles that.

 

4. Presenting to a consultant - FIRST - WHY are you calling them? You have to have a one sentence hook phrase or you are cooked.

Example: RLQ pain in a female

"Hello Dr. Surgeon, this is Bill Doe, PA in the ER. I have a 32 yr female with progressive RLQ pain for 26 hours with a loss of appetite and temp of 101. She has positive rebound tenderness at McBurney's point in the RLQ. She is not pregnant, does not have a UTI or ovarian cyst. Her WBC is 19K with a shift. She is thin enough for an ultrasound and it shows edema at the appendix. I am calling your for a surgical consult on appendicitis." 

 

You have painted a precise picture with pertinent facts and negatives. You are direct and confident in your knowledge.

 

Example: Dyspnea and peripheral swelling 

"Hello, Dr. Heart, this is Bill Doe, PA in the ED. I am calling about a 72 yr male smoker with HTN who presented to me with 3 days of progressive SOB with swelling in his ankles. He doesn't have a cardiologist. He is SOB on exam with an O2 sat on room air of 91% and diffuse crackles. He has 2+ pitting edema to both tibias. His BP is 178/98 and pulse regular at 80. His chest xray shows enlarged cardiac silhouette with blunted sulci, no overt effusion. He has a sodium of 135, K+ of 3....... He is responding to 4L O2 via mask with sats up to 96% and enzymes and echo are pending. We are calling for a consult and potential admit. He has no one here with him and he lives alone"

 

You can also end with - "what else can I get started before you or a colleague arrive?" or add "I have reviewed this with my doc and he/she agrees on consulting you". 

 

You shouldn't have to beg or justify otherwise.

 

I am 25 yrs in and you learn every single day - forever. You start putting away pearls and tidbits and you learn which cardiologist will hang up on you and which consultants will proctor you and give you golden opportunities to learn and help. Central lines were my gift from a pleasant and patient doc in the ER who appreciated my thoroughness and willingness.

 

GOOD LUCK.

You don't have to know all the answers - just where to go and look..............

[ventana]

one year to not be terrified of missing something, 3-4 years to be comfortable, 10+ years to really get it

 

It is not a quick process

[SERENITY NOW]

@RealityCheck, Thank you so much for the reply.  Those are extremely helpful suggestions that I'll work on.  I really appreciate it. 

 

@ventana, that what I suspected.  Its a long road!

 

[Guest Paula]

No kidding it's a long road.  

 

I am still having light bulb moments and I've been a PA for 11 years.  

 

I still obsess about some patients....did I miss something?  did I do the right thing? did the patient die overnight because I overlooked something or did not know what I should have? 

 

I expect I will  learn new things and strengthen my medical knowledge until the day I retire. 

[Guest JMPA]

read read read, and then read

[rev ronin]

read read read, and then read

I've got Harrison's in my bathroom. :-)  I rotate through texts, but I can't see exhausting that one anytime soon.

[browndog]

If you see something during a shift that you have to ask your SP about.....that is your homework assignment for the day. Read, ask questions, listen (to your patients, to your SP, to your colleagues) and most of all be patient with yourself. This is a process that cannot be rushed.

[SHU-CH]

Electronic medical records are my waking nightmare. When my hospital changed EMR systems it changed me from a somewhat regular per-diem to an almost never per-diem.

 

Presenting to a consultant depends widely on the consultant. Surgeons are usually terse. I once started the appendicitis routine described above and the surgeon interrupts me ten words in and says, "What's wrong with the patient?"

"Appendicitis"

"I'll be there in 20 minutes" *click*

 

Nephrologists on the other hand are often interested in granular details down to the color of the patient's underwear.

[True Anomaly]

To add to RealityCheck's really great writeup above, understand that some consultants may not respond very well to your request- and sometimes, flat-out refuse your request for admission or consultation. This is frustrating, to say the least, but talking to a consultant is a bit like throwing out a sales pitch- you have to know your audience. As noted above, surgeons can be very terse- my personal least favorite has always been urology. But one thing I've noted with consultants is that if you at least try to correct the problem yourself before calling they do seem to appreciate it- whether it's a difficult abscess you're trying to I&D, a reduction that may seem complicated but you give a decent try to reduce it, etc.

 

Remember also this- when you're studying the textbooks and the literature, it may recommend a certain course of action- like admission for a certain condition that's standard of care for that condition- but that's what the ER literature may say, and the consultant's own specialty literature says something else. Each specialty has their own deep body of literature that may recommend subtle differences in the management of these conditions we all encounter.

[BruceBanner]

The hospital environment is the school of hard knocks. There is so much protocol to learn, let alone clinical decision-making, and you are bound to step on a few toes and be straight up wrong more than once.

 

Agree with the above---consults are more of an art. For the first year you will probably feel like you are doing it wrong. Surgeons do tend to be terse. Other specialists vary. My advice---make pals with a few long-time nurses. They will tell you a LOT and save you some face as well.

[EMEDPA]

agree with Ventana- 1st year was comfortable with the basics but was constantly learning new procedures, diagnostic tricks, etc.

after 2 years was pretty comfortable with most ambulatory complaints. after 5 years was comfortable running an urgent care without a doc on sight. after 10 years was pretty comfortable running an ED solo and seeing all comers. I still learn something new almost every day from a specialist or a student who just heard a lecture on some new topic. you will never stop learning.

also agree with TA- have all your ducks in a row before calling the consultant. have all the relevant labs done and at your fingertips. review all the prior admissions for the same complaint. if it's procedure related, try what you can first. let them know up front why you are calling. when I talk to a surgeon it is in the first sentence: "Hi Dr smith, this is emedpa. I have a 24 yr old male with CT proven appendicitis who has been sick for 12 hours and has no other significant PMH. he's npo for 8 hours. " hard to argue with that.

[gbrothers98]

 

So my questions are:

How long did it take you all to get a decent grasp of these practical aspects of practicing medicine?

 

About 3 years but there were some things that came quicker. Learning curve for everyone is multifactorial.

 

Do you have any advice for new grads to speed up this painful process?

 

Realize it is going to be painful and there are no shortcuts. Just keep showing up and putting in the effort.

You have to develop both your knowledge base and procedural knowledge. Start on the knowledge base by reading the Cardinal presentations section of Rosen's EM and build on that by branching into injury/trauma and selected high yield medicine topics. Procedural knowledge is both patient procedures ie suturing AND the flow and process in the ED. Cognizant of your surroundings and your place and role in them is paramount.

 

Advice in general?

 

Since you are in the ED,  focus on symptoms and their evaluation.

Watch this video:

https://www.youtube.com/watch?v=2ZdQBjjTFGQ

 

 Advice specific to each bullet point above?

Get help about the EMR. You likely had some training. Go back to where this occurred and ask for more.

 

For every patient you admit or discharge, write down the process and reflect on this. You will see a pattern(s) emerge that you can base future decisions.

 

Start every discussion with a consultant with the following script: I am calling you about a (age) (gender) whom presents with (chief complaint for x time frame). This patient has (disease or injury) and needs a (insert specialty) consultation (in the ED, as an inpatient or as an outpatient). What else would you like to know?

 

The MDM in EM needs to focus on 2 things. First, why you dont think the pt has a life threatening condition. Second, why you arrived at your diagnosis, your treatment plan and disposition including action and time specific discharge instructions.

 

Processes seem random due to inexperience. An involuntary hold is actually a legal state mandated protective measure that is easily searchable in state statute and department policy. Go find the answer.

 

This is a common theme amongst new grads without prior experience in the ED other than a 5 week clinical rotation. Now you have to be a doer primarily vs an observer as a student. Take ownership of your new position and start figuring out how to transition.

Good luck.

G Brothers PA-C

 

 

 

[SERENITY NOW]

These responses are all very helpful.  I really appreciate it. 

[acozadd]

I agree with the read, read and read some more comments. If you enter a specialty, read the biggest books around for those specialties. Once you've read all the texts, stay up to date on recent research. In ortho, I've found no single text has all of the information that I want. Instead of having 10 texts nearby, I've created an easy to reference word document on my work computer that has a basic overview of all conditions I've researched thus far (now >250 pages after 3 years). It takes the best of all sources, along with clinical pearls I've picked up, and it's an invaluable resource. I started with the most common diagnoses in the first year, and now I have expanded it to everything.

 

If I were to work in ED, I'd pick the top 25 diagnoses and learn EVERYTHING ever written about them. Once you have these mastered, move on to other diagnoses.

[Sam I Am]

This story was told to me and helped to shape my PA career:  A young doctor started out his career with a blank notebook.  Whenever he made mistakes, he would write in it to help him remember and learn along the way.  Many years later, he had numerous books that were filled.  Why would he have volumes upon volumes after so many years?  If he learned anything from his mistakes, you would think he would have less to write about.  The reason is that he never stopped learning everyday.  

[whoRyou]

This story was told to me and helped to shape my PA career:  A young doctor started out his career with a blank notebook.  Whenever he made mistakes, he would write in it to help him remember and learn along the way.  Many years later, he had numerous books that were filled.  Why would he have volumes upon volumes after so many years?  If he learned anything from his mistakes, you would think he would have less to write about.  The reason is that he never stopped learning everyday.  

“Learn from the mistakes of others - you can never live long enough to make them all yourself.” - John Luther