career success and longevity in emergency medicine EM
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The practice of emergency medicine (EM) is consistently challenging. At any given moment during a shift, emergency physicians are responsible for making numerous decisions about multiple patients. Many of these decisions are time-sensitive, some a matter of life or death. Physical, intellectual, and spiritual fatigue can set in during or after a shift. Our consultants, clinic physicians, or hospital administrators rarely understand the roller coaster we ride. Out of necessity, those of us practicing EM look for ways to navigate the peaks and valleys that make up the natural rhythm of the emergency department.

I was recently celebrated for more than 30 years practicing EM in the same ED. Following this virtual luncheon, one of my talented new colleagues (David Cisewski, MD) asked me to share my secrets for longevity and career success. I figured others might be interested as well, so I crystalized 20 tips for emergency physicians (and perhaps all physicians) looking to achieve more joy, professional satisfaction, and wellness throughout their careers. I’ve separated them into 3 categories: Attention to Self, Mastery of Skills, and Finding Joy and Purpose.

Attention to Self

  1. Change your attitude from “woe is me” to “WOW is me” (Pearls from the Practice of Life). Dr. Peter Rosen used to say “Nobody woke up this morning and decided to ruin your day. Don’t get angry at your patients… Happiness is your choice.”
  2. Be positive whenever possible. Bring a positive attitude to the ED every shift. Start each day (or at least each shift) by asking yourself “Will I make war or peace with this day?”
  3. Nurture your health. Focus on and improve your diet, exercise, sleep, and spiritual wellness. Avoid drugs, tobacco, alcohol, energy supplements, and soporifics. Protect your time off, and schedule time for activities such as reading or exercise. Make time to connect with family and friends, as social isolation and loneliness put your health at risk. Some people now refer to these as the “new smoking” (Together: The Healing Power of Human Connection in a Sometimes Lonely World, also Relationships #8).
  4. Practice mindfulness. Some form of daily meditation, yoga, relaxation, or self-reflection such as journaling (which does not mean posting on social media) is beneficial. The proper use of and participation in the right social media groups and networks can provide support for some physicians. The positive effects from these activities can be present throughout your shifts, and often contribute to wellness and better sleep.
  5. Know when you need help. When you need help, get it without feeling shame or guilt. Seeking help is a sign of strength, not weakness. This must be a cultural shift in EM (and the medical profession in general). The more normalized that seeking help becomes, the better for us, our patients, our colleagues, our friends, and our families. Despite being trained to act heroically, we are nevertheless human and need (and deserve) support.

Mastery of Skills

  1. Work to improve your technical, communication, leadership, efficiency, delegation, charting, and relationship skills. Embrace beginner’s mind – there is always something new to learn. Commit to developing emotional intelligence (EQ), which is as critical to your success, longevity, and mental well-being as are the technical skills you learned in residency.
  2. Learn continuously. Every patient, consultant, EM colleague, advanced practice provider, nurse, and staff member has something to offer. Learn from reading textbooks and the medical literature. Discover what leaders in our field or at your medical center think or believe. Attend lectures and conferences related to EM or other areas of interest (including non-medical topics) to develop your intellect. Grow your knowledge base. As a bonus, you will have more interesting things to discuss with others.
  3. Relationships matter. Nurturing and cherishing them will help you feel satisfied during your career and throughout life. Foster and maintain healthy professional relationships. Get to know your co-workers in the ED. In addition, network with people outside of the ED (physicians and non-physicians). Always make sure to strengthen and prioritize relationships with your family and friends. Disengage from and avoid toxic relationships.
  4. Show interest in others. Be curious about what’s important to them, their lives, their families, and their interests. This gives your mind and heart a needed break from all things EM. Plus, it is the right thing to do and the best way to live.
  5. Develop good listening skills and show empathy. Understanding empathy (and being good at using it) will not only help you in your practice, but also with your relationships.
  6. Connect with patients and their stories. See your patients as people with lives outside of the ED. Patients are not just the “abdominal or chest pain in room 10.” (A Piece of My Mind. Gomer, JAMA 2004 and The Name of the Dog, NEJM, 2018).

Finding Joy and Purpose

  1. Celebrate your successes (even small ones) and your good fortune. Consider changing how you “define” success if your current definition doesn’t make you happy.
  2. Take one day at a time and, when possible, one moment at a time. Look forward to the future but immerse yourself in the present.
  3. Take pride in your work, your training, and your skills. Don’t lose confidence when you make an error. Instead, assume responsibility for your errors and don’t blame others. There are no failures, only growth opportunities. Commit to learning from your mistakes and from the mistakes of others.
  4. Work hard with intentionality and purpose.
  5. Remind yourself of the privilege and honor to care for patients who neither choose you nor have a prior relationship with you. Patients and their families are often afraid or have problems that they simply can’t handle without help. Be humbled by their courage to seek help, and that they’ve placed their trust in and hopes with you.
  6. Mentorship. Seek mentoring early from experienced, trusted faculty who will commit to your success with passion, integrity, and confidentiality. Mentors do not all need to be from your discipline, of the same gender, or of similar training, cultural, or socioeconomic backgrounds. It is reasonable to have more than one mentor supporting your growth. Throughout your career, keep in touch with mentors, and add new ones as necessary. When you are ready, take on the responsibility of serving as a mentor to “give back” to a colleague. (Mentoring in Emergency Medicine, Ch. 4, in Practical Teaching in Emergency Medicine, 2nd ed).
  7. Look forward to each patient and each shift as an opportunity to “cure sometimes, treat often, and comfort always” (Hippocrates).
  8. Express gratitude and offer sincere thanks. Think about thanking at least one person each hour. This doesn’t have to only be for major things; it can be for simple things and can be directed to anyone – patients, families, nurses, consultants, staff, colleagues, EMS personnel, and environmental services who clean up after us. Be sincere and specific with your gratitude. Even better, use people’s names as a show of respect.
  9. Keep a happy folder on your computer and establish a happy “area” in your office or home that has patient cards, gifts, perhaps your diploma, any recognition or important mementos, family items, and inspiring photos, quotes, or books. These items will likely make you smile, so refer to them regularly or as often as needed. Honor the impact you’ve had on others.

I hope these pearls help readers enjoy long and productive careers. I recommend reviewing the modern version of the Hippocratic Oath from time to time to remind yourself of medicine’s greater purpose. I also suggest Viktor Frankl’s book Man’s Search for Meaning. Although somber at times, Frankl beautifully relays the significance of finding meaning during life’s most challenging experiences. Our work in EM and healthcare in general is demanding, difficult beyond description, yet remarkable. As such, it has the potential to transform us in meaningful and lasting ways. I wouldn’t trade my last 30+ years in EM for any other profession despite the exceptional focus and effort it requires. Only by challenging ourselves do we learn the depth and breadth of what’s in our hearts. I hope that everyone reading this is fortunate to feel similarly about their career choices and clinical practices.

Good luck with your careers!

(special thanks to Laura)

Gus M. Garmel, MD, FACEP, FAAEM

Gus M. Garmel, MD, FACEP, FAAEM

Clinical Professor (Affiliate) of EM, Stanford University
Senior Emergency Physician, TPMG Kaiser Santa Clara
Senior Editor, The Permanente Journal