Final Words

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As I write this, my final EM Resident article in the role of EMRA president, it has now been 12 months since I completed my emergency medicine residency at Washington University in St. Louis. I have always looked to friends and mentors one step ahead of me in life for advice and to learn from their experiences, and in this article I hope to share with you a few thoughts to guide your thinking as you progress through training and shape your lives as emergency medicine physicians.

  1. Moonlight if you can.

We are fortunate in residency to know there is always help (often standing right behind us) as we learn to intubate a critical trauma patient or resuscitate a crashing patient peri-arrest. It is comforting and essential for patient safety early on for our attending physicians to be directly in­vol­ved in our training and patient care, but the experience and perspective we can gain from moonlighting can be priceless. I would argue that while the extra money you can earn moonlighting (save it or apply it all to loans, by the way) is nice, what is even more valuable is the change in mindset, knowing that if you’re at a small rural hospital, you’re “it” — if you cannot secure the airway, no one is stepping in to push you aside and save the day. Moonlighting, once you’re ready, is inval­uable in teaching you crisis perfor­mance and helping you identify gaps in your knowledge and comfort so you can address them before you graduate residency. It also offers you a look at community emergency medicine, so you can decide what type of practice fits best for your interests and passions.

  1. Face your fears head-on.

This advice applies whether you are studying for the Boards or just refining your clinical and procedural skills. Don’t shy away from areas that make you uncomfortable. If you know your slit lamp skills are lacking, make it a point to perform a full slit lamp exam whenever possible rather than simply doing a cursory exam with a bedside ophthalmoscope and consulting ophthal­mology (plus you’ll gain respect and credibility with your ophtho colleagues when you communicate your slip lamp findings to them in a consult). Everyone has areas where they excel (we all had that classmate who seemed to effortlessly secure every challenging airway on the first attempt), but it’s important not to rest on the laurels of your success. It can be hard to admit what we’re not good at, but doing so is the first step to becoming proficient and, ultimately, skilled in those areas. While you may stumble with your first few slit lamp exams, as you practice more and more, asking for feedback and help as needed, your skills will improve and your patients will benefit.

  1. Take full advantage of your teachers and mentors.

Academic emergency medicine faculty are some of the most interesting and passionate people you will ever meet, and they have committed their professional lives to sharing their knowledge with you. Don’t miss out on the opportunity to absorb every last drop of passion and knowledge from your attendings. Get them to share their stories and learn from their individual approaches and skillsets as you form your own armamentarium of knowledge and skills. Stay in touch with your faculty once you graduate – you may find an opportunity to partner on a multi-site research project or benefit from their expertise as you help update stroke or trauma guidelines at a community hospital.

  1. Start saving now, even though it’s hard.

Even if you somehow managed to have graduated medical school debt-free, the importance of learning the discipline to save and invest early cannot be overstated. You will be hard-pressed to find someone in retirement who regrets having saved too much money. Choosing the profession of medicine, many of us are already behind the curve in taking advantage of compound interest. Find a trusted financial adviser (know how they get paid) and learn the value of saving as little as $100 a month while in training, or more if you can. Financial discipline early will be one of your greatest weapons against burnout later as you find you are working because you want to, not because you have to in order to cover the payments on your new boat or car.

  1. When you first finish residency, keep living like you’re still a resident.

It can be quick and easy to forget how to survive on a resident’s salary once you stop doing it. If you can maintain the standard of living you had while in residency after you begin to earn an attending’s wages, you’re going to be golden. Use that extra money to pay off loans, invest, and save, and you will be so glad you did 5 and 10 years from now. Some new expenses, like specialty-specific disability insurance, are worth the investment, but try to resist the temptation to buy the biggest house just because you can afford it. A colleague once told me she was “saved by the dust bunnies.” On a tour of a home a real estate agent was pushing heavily, my colleague realized that just because she could afford a 6,000 square foot house, the cost of maintaining the mansion was going to be extreme, and not something she needed, or even really wanted.

  1. Reflect on what you want in your first “real job.”

Unless you moonlight, until the last day of residency, we have all been mostly sheltered in the ivory towers of academic medical centers. The reality is that job opportunities in EM vary greatly, and fewer than half of us will stay in academic careers post residency. Far more than just “community vs. academic,” your typical day as an EM physician will depend greatly on where you practice, the structure of your hospital or group, and what resources you have available. You’ll see jobs offered with insane signing bonuses, but be wary. Decide if you will be comfortable in your practice environment and if your family will be happy with the geographic location. Will you have access to consultants? How easy is it to admit patients? Who does the admit orders? What is the local standard of care, and is the hospital in a notoriously litigious area? What is the turnover rate for docs in the group? In short, it’s not all about the money, and in fact, it’s not about the money much at all. Be sure you’re looking for a group where the docs are happy and can take good care of patients – if you have those things, most any other challenge can be overcome.

  1. Stay connected with your class.

Your residency classmates are going to be some of your best friends. The bonds you form caring for critically ill patients and experiencing “you-can’t-make-this-stuff-up” moments in the ED are priceless. Make the effort to stay connected to your residency classmates, especially after you disperse across the world for jobs post residency. You’ll find you’re able to help one another in so many ways, from emotional support and inside jokes only those from your residency would get, to future job opportunities. Some of my classmates attended board review courses together, and others still vacation together.

  1. Implement a plan to keep learning.

After residency is over, besides the mandatory learning provided through ABEM via LLSA articles, we all need to find a routine that works for us to stay current in our medical knowledge. Each of us has a different style, but whether you choose podcasts, attending conferences, reading journals, or some other way, keep up the routine to remain a lifelong learner. Make a plan and stick to it – you’ll be glad you did, because the 10-year Con-Cert exam will be here before you know it!

  1. Stay involved.

EMRA offers us so many opportunities to be involved in organized medicine as students and residents (and even post residency as EMRA alumni), but beyond EMRA, it is worth the effort to remain engaged with the other professional medical organizations to keep you learning, teaching, and engaged with your professional colleagues. Dr. Nathan Schlicher (past EMRA Board member), told me at my first ACEP Leadership and Advocacy conference, “Pick a club and join it.” If you’re an AMA member through and through, you could be the next Dr. Steve Stack, the first emergency medicine president of the AMA. If you’re more focused on EM, be sure to block off time for your state’s ACEP conference, and you’ll be on your state ACEP board or serving as an ACEP councilor before you know it.

It has been a true privilege and the high­light of my professional career to serve as your EMRA president. I wish you the best in your professional and personal pursuits, and thank you for your commitment to EMRA.

Have your own tips to share? Tweet them to us @emresidents and @matthewprudy.

Matt Rudy, MD
Matt Rudy, MD completed his residency training at the Washington University in St. Louis. Having served as an EMRA Program Representative, Regional Representative, and as Speaker of the Council, he was elected as EMRA President-Elect in 2013.
Matt Rudy, MD

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