Dr. Gerard Rover MD

Teaching is supposed to be fun. But while you may experience your work as a long privileged day full of opportunities, your colleagues will be telling you the residents are getting dumber by the year. Here is an attempt to talk about teaching in emergency medicine that will help you rebuttal complaints from your fellow attendings

Complaint No1:

Those stupid residents are getting dumber every year

Answer:

no they are not, you are a dick

Complaint No2:

Residents never read an article anymore, they only read silly blogposts by midgets that present themselves as goeroes.

Answer:

(Me being 1.40 tall when wearing heels:)  There is nothing wrong with midgets or dwarfs, it is never about colour or texture of skin (like fur). Articles cater to old people with questions residents haven’t asked yet and they rightfully don’t give a damn. They will when they are as old and tired as you are. 

Complaint No3:

I have been teaching the same thing year in year out, I cannot bother to explain the same concepts over and over again. 

Answer:

If you don’t appreciate the joy of seeing young people finally understand essential concepts after years in college where they have been exposed to bad teachers and outdated textbooks, you should consider masturbating less and fucking off elsewhere.

If that wasn’t what you were after, I will leave you with a few statements on how teaching in emergency medicine should be done. Don’t read further if you are close to retirement and are only interested in flirting with nurses (in that case read https://doctorgrovermd.com/2017/03/21/nurses/)

Crucial points when teaching in emergency medicine

• Teach always. It is something that defines what you do all day. It is not a sidestep from business as usual, it is not something that can be taken away if the flow of the day demands it. It is part of your routine, part of your safety structure (If you ask a student questions it is a way of making sure you have covered all important things)

• Start with stating a problem. Whats is the problem? Why is this an issue? It is the clinical dilemma that you only start to see after some time in practice that you have to define first before you can elaborate on details. It pretty much is the answer to the question: Why is this relevant to me. Make the student understand what the problem is first.

• Make teaching fun, but never easy. What you teach, what you learn should always stretch you mental capabilities. 

• Always build on what they know already. 

• Repeat the important message at least three times. End the session with the message again and again and again. End the session with the message again and again and again. End the session with the message again and again and again.

• Teach about what you recently learned yourself. 

• Sing, draw, chant what you will but never ever use a computerised slide system. That is a no no for powerpoint, keynote and Prezi. 

• And finally:  Everyone that is in on the session is an equal. You are teaching someone to be a better you and the student is already becoming you.

I don’t know maybe I am getting old and the world is spinning too fast for me to keep up with. Maybe I missed a Lancet article maybe there is an ACEP guidance that failed to catch my attention, but somehow I have been getting the feeling that we are making way too many ECGs. 

When I grew up we were doing medicine based on a good history and a decent physical and we ordered tests only when every other option to us was exhausted. This (thank you for putting that out to me dear reader) included doing unnecessary surgery on patients with abdominal pain giving lasix to COPD patients and relying on meningismus to diagnose meningitis. But still, at least we put some effort into reducing testing. These days that incentive has long disappeared from the face of the (ED) world. I must admit I have grown to like the CT scan here and there, the point of care ultrasound for whatever occasion or even an ED TEE if you can… well because you can. What I have trouble accepting is this:

“Why on earth does every patient in the world always every time get an ECG and who orders these bloody things?” 

I am not talking about syncope or chest pain, not about shortness of breath or even suicide attempts. I am talking about patients with established covid infections, appendicitis and bloody ankle sprains. Everybody seems to be eligible for a twelve lead. Now don’t get me wrong I don’t mind the nurses putting on the rubbery sucky things on the patient’s skin – And I don’t mind the enormous paper waste (where do they get all that pink paper from anyway), It is a non-altruistic need for self-preservation: I need my life back. Because even though looking at an ECG may only cost me a few seconds, more and more I am feeling that my purpose in life has shifted from the relief of suffering to reading ECGs that I never ordered. 

So, wanting to stay away from the debate about who needs and who doesn’t need…. I want to propose the following thing.

ECGs for indications other than chest pain or syncope, or on the specific request of me can only be made if any of the following statements apply.

• The ECG was made by a nurse that was on her break
• The ECG was ordered by a junior doctor that first got me coffee (espresso, one sugar)
• The patient him or herself is either a cardiologist or a lawyer
• The doctor taking care of the patient is an orthopedic surgeon (because, well its funny to see them struggle)

Have you noticed in your practice that other people (never yourself) treat patients with medication that will probably work very well,  but is very very unnecessary? Sure you have. It is the kind of medication you probably wouldn’t take yourself.

I remember the old days where we had branded adrenaline as very effective for allergy, actually quite safe, but you know….. usually not necessary. As of today, some of our more intelligent doctors rebranded adrenaline as the only drug possible to treat allergy and they point at the disturbingly negative numbers and charts concerning antihistaminics and steroids. I have been called out at staff meetings for being an idiot that I do not give all my allergy patients adrenaline, because the data is out there isn’t it….

Now of course they are right.. They always are.  But that is not the point.

Allergy patients, (besides the acutely crashing ones) given some time and some over the counter medications usually heal fairly well without too much of our interference. And that should be the norm always. Stuff returns to normal. And as much as I like to act, start a drip, do a chest X-ray, the reality is that these patients do not really need us in the first place. Can we fix them fast? Yes we can, can we prevent one or two more severe cases? Sure we can. Will we save a lot of lives… naaaa.

But doctors cannot help but to act, and if the doctor has a lazy day, then certainly the nurses will act on our behalf. The fulfilment of years of training, the endurance of hardship in our faulty training programs, The suffering of many months of learning stuff by heart we are sure to forget after a day. Finally it all seems to have a purpose. We close the loop by doing stuff and making it all worthwhile. So we medicate…. a lot…. 

And somehow that seems appropriate – certainly  more so then saying “hello” to a patient and leave it at that. That would take a bizarre form of nihilism that we are not capable of imagining. Or can we? 

So hereby i propose to do the following from now on

DO give adrenaline in severe cases of anaphylaxis….. but

DON’T give everybody who shows up with a rash and a tummy ache adrenaline

DON’T give people that live in urban area’s and had some mild throat discomfort after ingesting an avoidable spice, the life-long discomfort of being scared all the time and carrying multiple adrenaline pens, while we all know that when the shit hits the fan they will not use it anyway.

Since it is obligatory to quote Shakespeare at least every 5000 words: “ all the worlds a stage, and the men and woman merely players” . According to Jacques in As you like it, men and woman live their lives in seven scenes describing their quintessential life fases.

Now this may hold true for most people, not for emergency doctors.

We daily report for another act and we are offered counter actors with varying amounts of proficiency or self respect. And yet, how bad these actors have learned their lines – it is all up to us to close dialogues, and continue the dramatic story in a logical way.

Now even though we, the doctors, are brainwashed in university that medicine is always the logical answer and even though we find ourselves confronted by thousands and thousands of medically unexplained symptoms, there are no acting classes in medical school.

Now to clarify and be very frank, I DO NOT MEAN ACTING WITH KIDS. For if there is one category of patients that will absolutely hate you for acting, especially if you are bad at it, it is the kids. Kids do not tolerate bullshit, Kids will tell on you, despise you and never trust you again in a life time. Adults however are simpler beings. They will not discover the acting, they want to believe you are genuine. If you say you feel sorry, they will feel it. If you tell them their complaints are very complicated, perhaps too complicated to be solved in the middle of the night by your humble night shift staff – they will sympathise.

Now are doctors good actors? Some of them are, some of them aren’t. But I can tell you that during medical school, residency and a later professional career, you are not tried and tested for it. Your yearly talk with the boss will not have a checkmark placed by acting skills. Your nurses will never confront you with it. They will say you have good or bad bedside manners, but will hardly every discover why.

So I urge you to do one thing today. If you are a healthcare professional and you know you sucked in the high school play, go online now, book an acting course and, what ever you do, DON’T PRACTICE ON THE KIDS.

Recently I read an entry on EMcrit where Scott W. describes a technique for stress reduction based on breathing techniques and focuswords. Now as big a fan as I am of Scott (or anybody that is shorter then me for that matter), we must see his advices as second tier. True stresslessness comes from apathy and nihilism. For stress basically is fear of losing control and the conviction that you are the only one that can fix stuff. What if I do something wrong, what if I miss something, what if I am wrong. What if the patient dies. Allow me to explain myself.

 

Step 1

The bigger the craving for control, the bigger the fear of loosing it.

this is basically about having faith in others. The more you rely on others, the less fear you need that that one will fuck up. So essentially, pick good team members, or better, know what they are able to do. Give them credit for what they do right and check up on them when you know they are in over their head. Assume they will be wrong at some stage in the game, but not likely in the first 5 minutes. Step in at the point where they are likely to do stuff wrong, but don’t where they are perfectly capable.

 

 

Step 2.

Balance yourself on the narcism / nihilism scale.

Basically we like to feel that as teamleaders we are influential. We set the stage, we dictate what happens in our resus-bay. You are able to steer the ship and dramatically increase the teams potential to do good. Without you things will not be ideal or perfect and that means you have to be attentive of every single detail.

This feeling should be balanced by the concept of realisation of futility. As we are well aware, many hard-fought improvements, high-tec or low-tec, have been shown to be pointless when looking at survival or quality of life. We can discuss the role of steroids, choice of fluids, magnesium etc. etc. In the long run and on a larger scale these medications may save lifes, but for your individual patient in front of you, they will not make a difference. So what if your team misses a dose of amiodarone, or forgets to apply a nasal cannula before pre-oxygenating your patient? As a teamleader you have to try to balance. Pick those interventions that will be a big deal for this individual patient and be strong there.

In conclusion

Try to have faith in your team, because you know at what stage of the game they will fuck up. And wait for that moment to intervene. And then, be a little more nihilistic and a little less narcissistic. 

As there is no profession anywhere in the world where you are studying so hard you loose touch with your family and most of your closest friends, but then still be looked upon as a pain in the ass by your peers, One would assume at least ones coach, teacher or educator would feel sympathetic towards the most awkward moment of medical teaching: The “end-of-a-rotation of 6 weeks duration conversation”.

Now, I don’t know what kind superhuman powers most medical educators posses (And god knows how many are bestowed upon me), but it seems a hard nut to crack to comeup with very specific and personalised feedback on a medical intern. Sure you have done one or two shifts with them, your colleagues may or may not have been  to busy or preoccupied to provide you with in depth feedback and of course interns suck big time anyway since in the earlier days everybody used to work so much harder.

And still, if you talk to medical students, or interns, they will all tell you that over their career they have been sitting down with the professor of such or the chief of so, the coach of specialty x and the student teacher of specialty Y. And if you ask them, what didthese conversations have in common? “All educators tried to judge not only our clinical work, but also our character”. And worse, they would invariably come up with a specification of the amount of knowledge the student may or may not have had. Of course they didn’t systematically look for character flaws – they just sensed…… They didn’t actually test knowledge with a knowledge test… they just knew.

It is about time, us clinicians and educators learn some modesty and when discussing a rotation of limited time, say anything between 2 weeks and 3 months, be consistent with the following 4 general rules.

1. The person you are speaking to is a peer. He or she has been studying for years and years and has given up so much of his or her time that it is safe to assume they have been extremely passionate about the trade of medicine. Maybe not your specific niche, but the trade yes.
2. You were pretty much of a dumb ass yourself thirty something years ago – you just forgot. It was 10 years after you finally became a consultant that you actually accumulated enough knowledge to say  you were no longer an ass. Unless you ctually tested for knowledge after telling the student what you would test for, do not make silly remarks about the amount of knowledge they supposedly have.
3. You cannot make a character judgement after a month of superficial contact. You can only tell about what an impact this person had on you personally. Stick to that. Don’t generalise. When you are using the words “you are the kind of person that…” or “People like you….” or even “You are just like me twenty years ago…”, stop doing what you are doing and put your head in a toilet.
4. Last but not least: In essence, unless you are going to remove someone from the trade for obvious malfunctioning, your goal is not to grade, to give a score or to say how somebody performed compared to others. The sole purpose of that conversation is to make that person a better doctor.  And that is it.

So I challenge you educators to abide by these rules the next time you’re having a conversation with your medical student, resident, anybody doing a short rotation on your ward or floor. Stop being an ass,  try to be a gentleman.

As most ED’s were designed, mine functions as a kitchen sink for the unfortunate, the lonely and the ones who never win. Now to be quiet honest, there is some beauty in this. For how many men and woman can honestly say they are open to each and everyone. And hospitals are placed in cities, that by default may not all be places of friendship, warmth and kindness. It is the harbour towns that still stand out. For centuries these places have have been important for sailors, drunks, and lost ones in general. Genoa, Amsterdam, Hamburg, Seattle,  Signapore etc.

Needless to say, with the disappearance of actual sailors one would expect these towns to change character but of course, they didn’t. The hospitals still find the same men and sometimes woman on their shores. Drunk, unresponsive, Alone.  Why you ask me? Well, as irony goes – Stag parties found their ways to the cities that have been catering drunk men all along. And as these young men roam the streets of our cities, dressed up as sailors, they recreate history somewhat.

And then the old question never fades: “what shall we do with the drunken sailor”.  And how much we would want to answer this one with “Put him in the brick until he is sober”.. We are more likely inclined to intubate and do a CAT Scan just to be sure.

And where does this leave us now. As my residents approach me with ECG’s, arterial bloodgasses, and heaven forbid chest X-rays of these poor people, I find myself more and more inclined to comment. For what, essentially do drunken sailors need? I will state here that what they need is Sugar, spice and everything nice

1. Sugar

Its the stuff we are supposed to check for.  A blood glucose. Someone at some point will have to have checked this. Will I double check? Of course not. Whatever the sailor has been up to, it wasn’t OD on his insuline. And, you will say, can alcohol not cause hypoglycaemia? Sure it can, but it won’t.

2. Spice

As seasoned emergency physician you have long time ago learned the hard way that in every case, boring, sad or faul smelling, you have to ask yourself the same question over andover again: What Spicy stuff could potentially be going on, and how sure am I it is not that? So I urge you, take 10 seconds on every sailor: what stands out, what is different? Is there  a bruise on his head? Think of trauma. Is there a weird position of his eyes? think Brain stam stuff. Is he too old to be drunk? Think infection and electrolytes. I he actually wearing a sailormen’s costume? Think HIV induced cryptococcal meningitis.  But, as I said before – think about it. Don’t routinely test for it.

3. Everything nice

If they are in your house, then why not: Keep them warm and dry for a bit, pour some coffee, some soup and some thiamine while you are at it. Most of all, they need a kind nurse to take care of them, check their vitals every once in a while and speak tender words. Now do not be mistaken that these need be female nurses as in many harbour cities, sailors tend to have alternative sexual preferences

Finally:

If this doesn’t make sense enough there are many more interesting acronyms that will fill your cup. “love eat pray” will work, so will “faith love hope”. As long as you are consistent and never forget: It is the sailors that give colour to this world, to this city, to this ED.

As everybody in healthcare knows, working in emergency medicine mostly means that you are making decisions on a constant basis. Usually you have to postpone two decisions to make a more urgent one first. Then you are obliged to make the former ones while you have forgotten the most important input to do so in the first place.

 

An attending emergency physician gets asked by the triage nurse if we agree with their triage, the residents need approval of their medical plan, the nurses need an OK for giving fentanyl and the motherfucking coffee lady wants to know if her diabetic patient may have sugar in his coffee.

 

All of these may seem to be valid questions (well most of them anyway) – but there is only inferno for the one that truly answers each and any question with the same amount of attention. With every reflection and honest validation of the information presented, your brain temperature goes up 1 degree and whether this is in Celsius, Kelvin or Fahrenheit – with the density of problems to solve in our field of business, at some point your brain will start to cook. A cooked brain leads to terrible decisions, a hostile atmosphere and most importantly you will have no brain functionality left to flirt with the nurses – which was why we are in this field of practice in the first place.

Science clearly shows that there is a limited amount of decisions one can make in a given time. When you pass this limit – you cannot do it any more. Your mind will go blank and even deciding what kind of coffee you like in your milk will become impossible to do. How to cope with this? Well clearly – Take less decisions. Just refuse to. At least 5 times a day stand up for yourself and state you will not be deciding this one. Out of self preservation, out of pity with yourself and because you need brain space for that witty joke to Nurse Bridget.

 

 

Nurses don’t need approval of what they do, they just need doctors to be there for them when it goes wrong. Don’t reflect on their triage decision – just say “I am with you on this one”. “If you decide that patient needs fentanyl, then I will gladly enter the order”.  The medical student that is in doubt wether to make an X-ray of a low risk limb, tell him: “whatever you decide, it will be fine as long as you involve the patient in the decision and as long as you don’t lie awake at night over this one”. And if the coffee lady is wondering about the sugar in the tea of the diabetic patient in room 6, tell her “tea is disgusting, real man drink whiskey”. And then wink at Nurse Bridget.

As a young medical student leaves university and gradually gets mentally altered into being a doctor – chances are he will be raising an eyebrow or two on certain matters. Indeed, there is very little sex in the hospital and medical staff in general has high self esteem and mediocre sense of humour. That alone leads to an atmosphere that can only be described as ‘suffocating’. It is therefor that I do not work in a hospital. I work in a little side building that is only minimally connected to the rest; The ER. For some reason the intoxicating sulphur smell of white coats and arrogance doesn’t seem to fully penetrate here.  But as all fantasies go – the good hearted docs and nurses in the ER sometimes are forced to communicate with the bastards inside the hospital and there starts my argument why doctors lie and manipulate.

Truth-full honesty can only live where equality is the norm.  Does that sound too minimalistic? Ok, How can you expect a normal being to behave when humourlessness and ego-petting is the norm?

Now don’t get me wrong, I have no problems with you petting something or someone (as stated before, there is way to little sex in the hospital) but ego-masturbation can only lead to one thing: a stone heart. So being or feeling equal is essential for men and woman not to lie steal and manipulate. In the battlefield, the soldier when asked by a general how he feels that day will not answer: “pretty bad sir, yesterday my closest friends died, as I watched I shitted myself and I haven’t slept because the foul stench kept me awake and so did the itch from the diarrhoea in my anus. Also, since my friends died – I want to kill myself and I seriously doubt if this whole war is a good idea.”  Let that one sink in. If this feels acceptable, then you can imagine why a junior doctor will lie to a professor. That is not unexpected. What is unacceptable though, is that this professor doesn’t realise this is the case and doesn’t compensate somehow for this.

When communicating across specialities the same logic applies. We don’t present the actual story to the heart-surgeon – we tell it the way he wants to hear it.

So can we fix this? Well it is difficult to change someone else, but often times we are put in a similar position when a GP calls the hospital. Do we realise the story isn’t the story? That we are given the manipulated version of it? The story is what apparently we want to hear, so the GP gives it to us.

So does this matter? Is this fixable? Yes it is when one considers this is reality. Equality is key – or better yet, change the hierarchy around.  Make the GP the one that decides, in reality but for certain in your mind. Let the GP be in charge, he or most likely she has already decided she wants you to see someone. Then the only question you can ask is “how soon”. Or “Thank you for thinking of our hospital… .Is there anything else I need to know about this patient”. Then you will get your story, the real, unaltered, not manipulated version of it. Can you do this?

If nothing else, it will change you from a sarcastic asshole into welcoming friendly professional. I bet that if we all made this change, the nurses will notice, and there will be much more sex in the hospital.

Dr. G. Rover MD

So as my conference progressed I slowly started to realise I have by now accumulated enough knowledge on how to visit a medical conference that I am able to enjoy it to the max.

Why is this difficult? Well, you travel a thousand miles and if you don’t follow these instructions exactly as I write these down, you will feel disappointed, tired and hung-over every single time. Allow me to discuss the 3 rules to make your conference comfortable and worthwhile.

1. Time

As it is nearly impossible to sit through a full conference without needing a brake, it all starts with saying out loud to yourself (not to anybody else) what part of the conference you are going to skip. You will use this time wisely for a stroll through town, running in the park or recovering from your hangover. Deciding this up front will eliminate feelings of guilt

2. Play

On the plane to your conference, think of stuff you will actually monitor for fun and then tweet about it. As an example, for SMACC 2017 I counted powerpoint slides that are on my personal forbidden list. End result: 3 icebergs, 2 eye-of-the-storms and 1 pyramid: impressively good for a three day conference.

3. Flirt

As you are far and far away from home, there is no better place to flirt then a medical conference. You are surrounded by the brightest minds on the planet, they are just as alone as you (but are being dishonest about it) and you get to see them several days in a row. Now we all know flirting leads to nothing but despair – but I can take some after three days of solid fun, greasy smiles and perhaps a dance or two with a beautiful tall dutch doctor that happens to have bought a new dress for the conference party.

Next chance I have, I will make handouts of these for your convenience. Until then Remember: Time, play and flirt.