residency graduation success sign

If you are graduating from an EM residency this year, you may be feeling nervous (or petrified) about your first shift out on your own. You’re wondering how you can gain the trust of the nurses and doctors at your new hospital. Perhaps you are wondering how you will keep learning without the residency leadership forcing articles and lectures on you.

In this post we will give you our top 10 tips, each with a practical pearl, for how to succeed your first year out. These keys to success will help keep you from making common mistakes, blowing your chance at a good first impression, and also help keep you out of deep, troubled waters when it comes to HIPAA violations and keeping your medical license.

Tip 10. Set Goals and Find Mentors

You’ve probably been told at some point that you should write down your 5-year and 10-year goals. If you haven’t been told that, then we’re telling you now! If you do not have your goals in mind, then it is easy to get drawn down tracks that you are not truly interested in. For most of the last decade, the majority of your decisions have been laid out for you to make. The necessary steps have been mapped out neatly for you: MCAT, medical school applications, USMLEs, and the match.

Now that you have graduated, the world is wide open. You could develop a niche in ultrasound if you want, become a department administrator, develop your teaching skills, or start writing. In order to pick the right opportunities, you have to know where you want to go in the future. Unfortunately if you do not set your path towards your goals, you can find that in 5 or 10 years, you are not where you wanted to be or have not achieved what you had hoped.

As a practical step, we recommend that you sit down and think through your 5- and 10- year goals, and write down what you need to do to get there. It’s a great idea to talk to one of your faculty mentors or residency leadership about how you can attain those goals. Is it to be in a specific leadership position? To speak at ACEP? Your faculty members who have done these things can tell you how to get there.

Tip 9. Play Well With Others

You are probably moving to a new “sandbox” after graduation where you will need to make new friends. That includes both socially and professionally. Start at work. Talk to people: co-workers, nurses, technicians, consultants, janitors, staff, etc. Make eye contact and smile at people in the hallways. Be sure to introduce yourself. This will be easier to do when you can say “Nice to meet you. I’m the new guy (or gal)!” rather than months or even years after you start. We all know that awkward moment when you talk people you SHOULD know but never really met or learned their name. Consults and admissions will be so much easier when the person on the phone is a friend, rather than a stranger. You might even find out you have common interests outside of work, like family or hobbies, and begin a social friendship.

Tip 8. QI Yourself (Quality Improvement)

During residency, you have had an attending looking (or lurking) over your shoulder every minute! They have given you big and small pieces of feedback to help guide your medical thinking, your procedures, and teach you how to run an ED. Now that you are on your own, you will need to do that for yourself. Practically, that means thinking about and reflecting on how you are doing. If a code went particularly smoothly, figure out what it was that made the communication tight and the teamwork on point. If something did not go well, it is even more critical, but also more painful, to reflect on what happened. Figure out what you could do better in the future to make sure you are constantly improving.

It is generally believed that you are not an expert emergency physician until about 5 years out of residency, so keep self-reflecting on your practice. Did you miss a subtle STEMI on an ECG? Spend some time reviewing ECGs. Take a course on it. Read some books on ECGs. Did you flounder running a code? Ask for honest feedback from your nurses. Look for simulation opportunities to practice your skills. Run through scenarios with a friend who can give you honest, thoughtful feedback. Practice and rehearse what you will do next time a coding patient presents via ambulance.

Using deliberate practice in this way, you can turn your past failures into future successes. If you do not do this, then your skills will atrophy rather than grow, and you could find yourself having practiced for 20 years but with skills no better than a senior resident.

Tip 7: Get Your Paperwork Done on Time

Soon you won’t have your amazing residency coordinator sending you 15 reminders while beating you over the head to get that boring, painful stuff done. Charts, licensing requirements, and hospital modules are all necessary parts of keeping your job. The paperwork is not as glorious or rewarding as saving lives, but it is important and generally easy. Do not end up on the naughty list with hospital administration for simple, albeit tedious, tasks. So, get your charts done on time. Respond to emails in a timely manner. Be polite and grateful to support staff and they will make your life easier.

Tip 6: Keep Learning and Stay Humble

During your career you will not only have to relearn all the things that you are continuously forgetting, but you will also have to learn completely new things. For example in the last 5 years, novel oral anticoagulants (NOACs) and other entirely new classes of medications are now available. Physicians need to learn how their indications, doses, and their complications. Physicians who graduated 20 years ago probably did not know a linear from a phased array ultrasound probe. In order to stay current, you too will continually have to learn new skills and treatments. Thus remain open to and pro-active about learning new things.

During residency you have had learning forced on you with lectures, required journal clubs, podcast assignments, and the in-training exam. Now that you are on your own, you have to motivate yourself to learn. Practically, this means planning time to read and choosing some high quality resources. Picking a few high profile journals or articles a month is a good place to start. However, no one can stay up to date on all the journal articles, so it is a good idea to pick secondary sources (such as blogs or podcasts) as well. Keep up your subscriptions to the EM journals, podcasts, or online resources that you liked during residency. If your program or hospital does not already have a journal club, consider starting one. If no one else is interested in a journal club, then pick one of your residency buddies, read the same things, and discuss them to keep each other accountable. Peer pressure and the fear of looking incompetent are great motivators.

It is also important to stay humble. There will always be more for you to learn, and there will always be syndromes, complications, and diseases that you have never heard of. So never become too proud to learn from your colleagues, consultants, nurses, and your patients.

Tip 5: Discharge Abnormal Vital Signs with Caution

Not to say that you can NOT discharge these patients, but do it only after you have really thought about what you are doing. Use it as a self-check to re-run your differential diagnoses and treatment plan. For example, your internal dialogue may be:

Good example: “The patient in room 5 can go home with atypical chest pain because they can’t have a PE since they are PERC negative…oh wait… their heart rate is 115…so I can’t use the PERC rule… let me re-think this…”

Bad example: ”I am OK with room 10  going home with a HR of 110 because I know they have missed their beta blocker today and probably just have reflex tachycardia.”

Tip 4: Respect the Things that Can Get You Fired

Nothing will get you fired faster than a social media HIPAA violation. While a post on your “closed” Facebook group may seem innocuous, hilarious, or educational, it is extremely important that you never include any identifying information. While 99.9% of the Facebook group may share your sentiment, or may even appreciate the educational point you are making, your department chair may also be a part of the group and may not appreciate it. Or a disgruntled or even a well-meaning colleague may report it to your institutional privacy office. Being investigated by your privacy office or by your state medical board is no way to start out a new job. So be extremely cautious.

Also, don’t be reckless. Do not post pictures of yourself drunk online! Do not drink and drive! If you have a DUI, you will have to report it every year when you apply for your medical license renewal and every time you apply for a new job. For jobs in highly competitive areas, you will not want any red flags on your application, even if you are an otherwise fantastic clinician.

Tip 3: Follow Your Gut

You have studied and worked hard for countless hours in identifying sick and not sick over the past 3-4 years. You have seen thousands of patients and have begun to develop a 6th sense, or a “gut feeling”. If your gut tells you something isn’t right, listen to it. When the x-ray looks odd to your trained eye despite the radiologist’s negative read, listen to your gut and follow through. If your gut gets queasy at the thought of discharging the 2.5-month-old with a fever or the 95-year-old lady with a fall, listen to your gut and keep them for observation. Your gut is well-trained and usually right.

Tip 2: Do Not Feel Bad About Ordering or Admitting More

While following your gut will work most of the time, sometimes it is a struggle to clearly identify the underlying problem or diagnosis. So if you are in doubt about admitting a patient or ordering a CT scan, do it. Do not feel bad about having higher rates of admission or testing than the clinicians who have been practicing clinically for 10-20 years. It is expected that you will be more conservative initially. If you do find yourself worrying after you discharged a patient or are concerned that you missed something, do not forget that you can just pick up the phone and call them! Patients love having their doctor call them to check on them, and it provides a chance for you to allay your worries, reassess their condition, make sure they picked up the prescription you sent, and reiterate when they need to return to the ED.

Tip 1: If You Hate Your Job, Leave It!

About 50% of emergency physicians change jobs within their first 2 years of out residency. There is no reason to continue and persevere in a job you hate. You are not a failure for leaving a job. Many of us do not know exactly what kind of practice is right for us immediately post-residency. We do not know the right questions to ask when interviewing or signing a contract. Luckily, the opportunities for emergency physicians are endless and diverse. You can find a better job fit for you. Not leaving may be the one thing keeping you from your ideal job, happiness, and success.

A Caution and a Benediction

You can practice anywhere in the world, master any sub-specialty from deep sea medicine to aeronautic medicine and everything in between. You will find that the greatest challenge is not the actual medicine but in maintaining your humility, altruism, optimism, kindness, and grace in the face of limited resources, tragic outcomes, a chaotic environment, and a system that often works against rather than for the patient.

We hope that as you graduate you will find patients who inspire you, co-workers who support you, and mentors who help guide you towards a long and fulfilling career in Emergency Medicine!

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Christina Shenvi, MD PhD
Associate Professor
University of North Carolina
Christina Shenvi, MD PhD


Emergency Medicine and Geriatrics trained, Educator, Professional nerd, mother of 4, excited about #educationaltheory, #MedEd, #EM, #Geriatrics, #FOAMed.
Christina Shenvi, MD PhD

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Nikki Binz, MD

Nikki Binz, MD

Residency Program Director
Department of Emergency Medicine
University of North Carolina at Chapel Hill