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Dear Residents: 10 Things Your New Chiefs Want You to Know

2018-10-28T21:23:33+00:00

Need to Know canstockphoto13987731 This month starts our inaugural ALiEM Chief Resident Incubator and this post is the culmination of a 7-day intensive writing project by our 100+ Chief Residents. Incredibly we were impressed by the caliber of writing and insightfulness of our members. Congratulations especially to the lead editors, Dr. Melissa Joseph (LAC+USC) and Dr. Jimmy Lindsey (Univ of Chicago). Looking forward to an exciting year ahead of us!

10 Things Your New Chiefs Want You to Know

1. Education is not a spectator sport

Melissa Joseph, Chief Resident, LAC+USC, Los Angeles, CA @socalmeli @lacuscdem

As nervous as we are to take on the challenges of being chief, we are equally as anxious to see if you will rise to your new roles as well. Emergency medicine is pioneering open-access education, high-yield lectures, innovative conferences, and flipped classrooms, all of which are changing the game for resident learners. However, none of these concepts work without your participation and input. It is easy to sit back and expect to be spoon-fed delicious knowledge, but it is up to you to take full advantage of your time as a resident. As much as it is on us to give you access to the clearest, best, most useful information, it is on you to be involved, innovative, challenge the status quo, and be an information sponge. In his TED talk, Alexei Kapterev encourages a “cross-pollination” of different learning strategies and experiences to maximize learning.

So, participate! Take on projects that make you nervous, read, teach your juniors (or medical students, or seniors!), step into your new leadership roles, start a blog, develop your ideas, utilize your faculty and chief mentors, become a self-taught guru of something, and truly maximize your education during residency. By the end of this year, we hope to make a positive impact on your ability to learn, but your own drive may prove far more rewarding and long lasting.

2. When you feel like crying, cry to me.

Rory Stuart, Chief Resident, Wright State University, Dayton, OH @rstuart78 @WrightStEM

Over the upcoming years, your current sense of energy and excitement will be tempered against the challenges that lie ahead. You will be more exhausted, overwhelmed, disgruntled, and frustrated than ever before. You will battle against disease, injury, and hospital bureaucracy, and you will often lose. You will question the decisions you made during your last shift, your desire to go into emergency medicine and, at times, you’ll rue the day you submitted your medical school application. You’ll find that you cannot convey, with any degree of accuracy, what it is you actually do on a daily basis and find it harder to keep in touch with family and old friends. Know that every one of your attendings and senior residents continue to go through these same trials. When you find yourself on the ropes and feeling utterly alone, call us. We might not be able to make that Surgical ICU rotation any less painful, but we’ll at least buy you a beer and share some stories from our own days working the surgery salt mine. We’ll also tell you to not live and die by your daily victories and defeats; for every bad shift that leaves you feeling like Charlie Brown, there’s a champagne tap around the corner just waiting to rekindle your inner Arthur Fonzarelli. We’ll remind you that when you have a day off, take a day off. Don’t underestimate the ability of your workaholism to quickly become a smartphone, social media, and online medical record mainlining fiend who will morph into a 24/7 neon-pulsating concretion of caffeine and obsession. It’s our hope that you don’t overlook the nuanced curriculum of joy, sadness, humility, and humanity that is an emergency medicine residency. There’s no way around it; it’s the price of admission to this great profession.

3. Play nice in the sandbox

Glenn Paetow, Chief Resident, Hennepin County Medical Center, Minneapolis, MN @glennpaetowmd @HQMedEd

sandbox

We work in a very complicated sandbox and quite frankly, it’s impossible to do what we do without help from everyone around us. Techs, nurses, social workers, medical students, co-residents, consultants— we rely on their help to get the job done. There will be times when you are feeling exhausted, frustrated, and overworked. It’s easy to point out someone else’s mistake, to lash out and say something insensitive, or continue to fuel a heated conversation with a consultant. It is much harder to stay above the fray. Remember that everything you do is for the patient. Do not allow the pressure of being a resident prevent you from providing the best possible care. Invest time into maintaining strong relationships with your nurses and techs. They will be your greatest allies. Learn their names and ask how their kid’s soccer tournament went last weekend. When you are off service, remember that you represent your residency program and the entire specialty of Emergency Medicine. Learn everything you can: their language, their physical exam skills, their way of doing things. Be professional. Never bash another specialty. When dealing with difficult consultants, keep a cool head and remember that it is in your patient’s best interest to have the conversation go well. Push yourself to improve your consulting skills. 1 Know what you want to say and how they want to hear it. Organize your thoughts and anticipate their questions. Forgive them if their communication skills aren’t up to par, but don’t forget that your patient deserves their attention. Welcome differing opinions and use them as opportunities to learn. But above all, be nice.

4. Burnout happens. We’ve got your back

Nicole Wojtal, Chief Resident, UCSF-Fresno, Fresno, CA @ucsfdem

Being an emergency medicine resident is both incredibly awesome and astoundingly difficult. You are asked to work extremely hard for a modest salary in a broken system. You do not have enough time to take care of yourself and most of us, at some point, question whether or not it’s worth the struggle. In fact, a 2014 cross-sectional study of 8 EM residency programs showed 65% of us met criteria for burnout. 2 Burnout feels bad. We grow emotionally exhausted, cynical, feel clinically ineffective, and become disconnected from coworkers and patients. 3 Unfortunately, there is no well-studied cure. Only you can answer what it means to be a fit resident – emotionally and physically. Sometimes, this means having to say, “No”. A work ethic based on self-sacrifice and denial may end up harming you and your patients. We know from personal experience that talking with co-residents helps, and we assure you that we will listen. You already know that sleep, exercise, and nutrition will improve your mood but we encourage you to do the things (when you can) that give you a sense of connection and meaning. We want you to know that as chiefs we’ve got your back. We are invested in your well-being, we will work to promote resident wellness, and we’ve been there.

5. We are a team

Valerie Cohen, Chief Resident, Christiana Care Health System, Newark, DE @ValerieCohenDO @ChristianaEMed

“Interdependent people combine their own efforts, with the efforts of others to achieve their greatest success.” –Stephen Covey

We are about as interdependent as it gets, having spent hours, days, and years together. We see each other more than we see our own families! We have gotten each other through some of worst shifts and most exhausting months that we will ever experience in our lives. Without even realizing it, we are making each other stronger and more successful every day.

“None of us are as smart as all of us.” – Ken Blanchard

Our learning should not only take place during scheduled conference time; we can all learn from each other. Share your successes and failures. Teach us all what you know, and what you wish you would have known. When we get out on our own, we all represent this residency program. Together we can make each other and this program better.

“Teams share the burden and divide the grief.” –Doug Smith

You are never alone! If you had a bad experience, come talk to us. Talk to your co-residents. We are in this together. We all share in the ups and downs of this collective group. We all have the patient stories that we love to tell and the ones that still haunt us at night. Sometimes the hardest of times shape us the most. Rely on your teammates to get you through. Everyone in your class is going through the same exact thing! Learn to appreciate the process together.

6. Neither residency nor life are fair. Use it as an opportunity to shine

Jimmy Lindsey, Chief Resident, University of Chicago, Chicago, IL @jylindsey @UChicagoEM

As EM residents, we are part of a vibrant, diverse community of intelligent and driven individuals. Your coresidents are successful, infinitely fascinating people who share your passion for life and learning within the field of medicine and beyond. These colleagues also share in the tribulations that envelop your residency experience between the innumerable chaotic shifts in the department: missing family reunions, relationship woes, the aging, ailments, or loss of loved ones seemingly (and sometimes truly) half a world away. We also ALL aim to find joy and inspiration in our non-medical pursuits: to toast to a college friend at their wedding, attend that playoff hockey game (Go Chicago Blackhawks!), and yes, even to make it to the Thursday midnight showing of Fast and Furious 7. As chiefs, the reality is we can’t make everyone happy. Sometimes the schedule or shift swap you wanted, the opportunity or position you applied for, or the flavor of energy drink you wanted from the cafeteria (the struggle is real) doesn’t pan out. We know there are nights when you’ll feel like you’ve done 10 pelvic exams while your co-residents are intubating, chest-tubing, crash fem-lining, push-dose pressoring, and lateral canthotomizing everything that moves. Know that we, as your chiefs, follow the doctrine that no one individual’s free time is more valuable than another’s. Your week long string of night shifts was not borne of malice or vendetta. We try to make decisions that are in the best interest of the program and we ALWAYS consider your requests. Your faculty, chiefs, and colleagues are paying attention to how you react to these perceived slights. When you take that extra shift in stride, we’ll notice. When you take on a task that nobody else stepped up for, we’ll notice. When you swap into a weekend night shift so a co-resident can celebrate an anniversary or birthday, we’ll notice. Flexibility and adaptability are leadership skills; some of the best career opportunities may come from how you reacted when the situation was suboptimal. Neither residency nor life are fair. Use it as an opportunity to shine.

7. Think before you click

Anand Gopalsami, Chief Resident, University of Chicago, Chicago IL @biggops @UChicagoEM

Remember that frustrating attending interaction, the weekend you asked off 4 months ago but did not get, or the same resident who jeopardized you again? Getting angry? Good, now do nothing. The first instinct may be to sit down and draft that long email to your program director, cc the chiefs, the CMO, and the local newspaper to rectify the wrong that was done. You sit down, re-read your draft, and feel good about the decision to air your grievances. The send button is clicked and you crack open a beer to wait until things become perfect. It never seems to work that way, though. Things don’t become perfect, and 30 minutes later you feel that deep knot in your stomach when the PD sends you a curt one-liner back. Email and social media are a wonderful way to communicate; the ability to convey thoughts in warp speed and collaborate in real time is amazing. But it is also permanent – your one page rant will be set forever in stone. Speaking from experience, never send an email or write a post you would not want the entire world to read – a digital communication leaves no room for interpretation. Real change never happened through an 84-draft string of gmail rants.

As your chiefs for next year, work with us to make the impact you hope to see. Meet in person, have an agenda, and propose realistic solutions. Being the consummate professional will earn peer respect and you may find it to be far more rewarding.

8. Use us as career mentors

Todd Schneberk, Chief Resident, LAC+USC, Los Angeles, CA @lacuscdem

As chiefs, we are not only a confidant, but also a career resource. We were just in your shoes. We jumped all of the same hurdles and have an intimate knowledge of the challenges and opportunities within our programs. We are more than willing to listen, to provide a picture of how our path unfolded, and advise how you can maximize your efforts to reach your own goals in residency and beyond. Our task is not only to support you during residency, but to also propel you into your future. We are constantly astounded by the prior accomplishments of our juniors and the skills you possess. Yet, sometimes residents become entrenched in their clinical duties and forget to pursue the endeavors that impassioned them in the first place. These experiences helped shape you into the fantastic applicant that got into our program, and it would be a waste to squander those talents due to lack of mentorship. 4 We can point you to the faculty members or committees to approach, give advice on entry steps to projects, and make introductions to faculty at our institution or elsewhere as needed. Mentored residents are more likely to report better career preparation than their non-mentored colleagues. 5,6  Chiefs can be a sounding board for your ideas, providing feedback on how to proceed with a particular inspiration as well as how to navigate the potential challenges.

9. It’s all about trust

Sri Patel, Chief Resident, Hackensack UMC, Hackensack, NJ @HackEMRes

As emergency physicians, we have been trained to have our doubts about trust. Who do we trust, what can we trust, why should we trust? We have all heard the teachings throughout medical school: Trust no one. All disease states lie. “Don’t fall for that; I once saw an acute MI in a 20 year old with chest pain for 2 seconds.”

Here are the things we want you to know about this mysterious force known as trust:

Trustworthiness is the framework around which we build trust. In an excellent talk by Onora O’Neill, she describes the 3 essential components to trustworthiness: Honesty, Reliability and Competence. Mastering the road to trust requires a strong foundation in these areas and, in turn, fosters immense personal growth.

Learn to trust yourself. This is a fine line – while confidence is great, over confidence can be downright dangerous. Arthur Ashe put it best, “One important key to success is self-confidence. An important key to self-confidence is preparation.” Practice self-trust daily.

Trust that you’ll mess up. Didn’t we just say to trust yourself? The acceptance that you are not infallible will make you an even better emergency physician. Mistakes should be rare, they should be examined closely, but they DO happen and we trust that you will overcome them.

Trust each other. Residency is not a few years with some random people whom you will never see again. This is your new family and with that you gain an army of people to rely upon for the rest of your career. Learn from them, lean on them, and most importantly trust in them, and they will learn to trust you as well.

10. Find Your Voice and Use It

Maggie Sheehy, Chief Resident, University of Illinois at Chicago, Chicago, IL @mksheehy @UICbrowncoat

Effective communication is essential to becoming a successful emergency physician. Communication improves patient safety and satisfaction, solidifies relationships with coworkers and consultants, and increases physician satisfaction.

Talk to your patients. Many residents will experience imposter syndrome. Initially, something such as introducing yourself as “doctor” can feel strange. Don’t let this deter you. Work to build your confidence and always explain results, plans, and dispositions to your patients.

Speak with families. These are some of the most difficult conversations you will have in residency. What you say and how you say it matters. The family is lucky to have someone as sympathetic and kind as you to deliver the news.

Speak with nurses and find your trauma voice. Your ability to articulate ensures the best outcome for your patient. If you are in charge of a resuscitation, someone should be able to walk into the room and tell immediately.

Speak with consultants.Be a resident who has the magic touch with consultants.

Speak up within the residency. The greatest asset to any program is, and always will be, its residents. If you want to change something, to give a lecture, to share a special interest, let us know. We want to create best possible opportunities for you.

Speak up for the specialty.Stand up for the specialty which cares for the sickest and most vulnerable. Advocate within your hospital, your country, your world. Find your voice and use it. We will be listening!

The upcoming year will hold new challenges and learning experiences for all of us. Know that our door is always open for you, and we shouldn’t be hard to spot in the department: Chief Residents in the House!

© Can Stock Photo

1.
Kessler C, Kutka B, Badillo C. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med. 2012;42(6):704-711. [PubMed]
2.
Kimo T, Ramoska E, Clark T, et al. Factors associated with burnout during emergency medicine residency. Acad Emerg Med. 2014;21(9):1031-1035. [PubMed]
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Spickard A, Gabbe S, Christensen J. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288(12):1447-1450. [PubMed]
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Sambunjak D, Straus S, Marusić A. Mentoring in academic medicine: a systematic review. JAMA. 2006;296(9):1103-1115. [PubMed]
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Yeung M, Nuth J, Stiell I. Mentoring in emergency medicine: the art and the evidence. CJEM. 2010;12(2):143-149. [PubMed]
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Ramanan R, Taylor W, Davis R, Phillips R. Mentoring matters. Mentoring and career preparation in internal medicine residency training. J Gen Intern Med. 2006;21(4):340-345. [PubMed]

Expert Peer Review

You deserve our congratulations for putting together this remarkable collaboration! I know of no other published open letter like this. Your group is diverse in gender and geography and represents a wonderful mix of thoughts and advice. What a great platform to engage your colleagues.

I am just now finishing my Chief Resident year and wish I had thought of something like this 12 months ago. I hope my experiences over the past year can lend some insight into your writing.

Overall, so much of what you write is spot on. It is indeed important to share these sentiments and your writing gives your juniors a good sense of what you value and how you think.

Starting with education, Dr. Joseph’s charges residents to participate and take control of their learning to maximize their training. I couldn’t agree more. The difficulty lies in how to motivate learners to do that. This post is a good start, but the challenge will come once the academic year is in full swing and people are tired and burnt out. Along those lines Dr. Schneberk also implores his colleagues to take advantage of the chiefs for career advice. I hope the new chiefs can fill this role in connecting juniors to the right mentorship.

Speaking of burnout, Drs. Stuart and Wojtal give one of the most important messages chiefs can give. Your residents have to know that it is ok to have a hard time and to feel some form of burnout. The sentiment he shares, “we might not be able to make that SICU rotation any less painful, but we’ll at least buy you a beer and share some stories…” is one of the most effective examples of leadership that I can think of. I can’t tell you how many crises have been averted and how many residents have been walked off the ledge by having a beer with a trusting colleague. This is huge. Dr. Wojtal punctuates the attitude when she writes, “we’ve got your back.”

Drs. Paetow, Sheehy, and Cohen touch on important elements of leadership, teamwork, and communication. These topics are hard to teach but are absolutely vital in professional development. The job of the Chief Resident is to model this behavior at all times. Your co-residents will look to you now as an example of how to consult, how to play nice, how to communicate and you must rise to the challenge. You must quickly become communication experts in the different domains listed by Dr. Sheehy.

The concept of trust among residents is fraught with difficulty. Dr. Patel’s model of honesty, reliability, and competence is what we should strive for. It is absolutely important to be trusted as chiefs. There are times, however, when confidence between resident and chief must be broken (e.g. a resident shows up to work intoxicated). Clearly outlining the circumstances when the chief has no choice but to involve the Program Director would go a long way toward ensuring no one feels their trust is violated.

“Think before you click” is so crucial. I’ll pretend I have no personal knowledge of this topic and let Dr. Gopalsami’s lesson speak for itself. The stock email program on Android lets you change the setting for “delay email sending” so that you can cancel after you click send. I may or may not have mine set to 30 seconds.

Finally, the tough love comes from Dr. Lindsey. This is what I was waiting for as it will account for so much of your personal struggle this year. So much time and emotional energy is spent on the schedule and all the issues that surround it. It is a good reminder to the troops that you are human and are doing your best for ALL residents, and sometimes that means that people don’t get what they want. If only this message would sink in. Part of your challenge is to be stellar in the other areas of leadership so that you have credibility when this inevitable challenge arises.

To this stellar group from Los Angeles to Chicago, Fresno to New Jersey, Ohio and Minneapolis to Delaware: thank you. This was a treat to read and I hope it is broadly circulated to all residents. It concisely conveys several crucial messages that give those you lead some insight into the mind and heart of our Chief Residents.

Jeff Riddell, MD
ALiEM Assistant Editor
Diagnose on Sight series;
Chief Resident
UCSF-Fresno Emergency Medicine Residency
Michael Gisondi, MD

Michael Gisondi, MD

Associate Professor and Vice Chair of Education
Department of Emergency Medicine
Stanford University
Editor, ALiEM EM Match Advice series