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Author: Wojtek Sawicki, Ray Raj, John Murray, Ruth Suckling, Tom Wiles / Codes: SLO7, SLO8, SLO9 Published: 10/01/2015

1. You are not alone – Wojtek Sawicki (WS)

It can be easy to be overwhelmed initially by the fact that you have now become the clinician who the buck stops with. Don’t think that now that you have become a consultant you will know everything about every condition that may present to the ED. The intrinsic nature of emergency medicine is such that it is nigh on impossible not to come across a condition that you didn’t wish you knew more about. Accept this and you will lead a more contented clinical existence. By all means strive to better yourself, but don’t be afraid to ask for a second opinion or advice from your consultant colleagues, not just in the ED, but also in other specialties. We all have days in which we are less sharp than usual, and sometimes all you need is a colleague to verbalise what you are already thinking. Don’t let your ego, or fear that you may appear foolish, get in the way of safe practice.

2. Don’t take anybody else’s word for it – Ray Raj (RR)

In a busy department, it’s often reasonable to be looking after several patients at once and unfortunately, you can’t be with each patient all of the time. There are many instances when you will get a verbal report of results to act upon and you may even find that your notes have been acted on following the results of particular tests. I have found, to my despair, that human error is unavoidable, but don’t let someone else’s error be yours. Do check all test results yourself and ensure that the appropriate action has been taken. When starting as a consultant, I had learnt that a patient was discharged to a psychiatric unit with a presumed normal paracetamol level following an overdose. However, the same patient returned a few days later in liver failure. Looking back, I realised that the report had not been ‘normal’ at all, but ‘n/a’, which suggested the lab could not test for the drug rather than there was no paracetamol detected and the clinician involved had made a simple error when interpreting the result.

3. Resist the routine – John Murray (JM)

As an ED consultant, you will see hundreds and thousands of patients every year. It is easy to become cynical and blasé. Treat every patient with the same respect that you would like to be afforded to a member of your family. Enter every cubicle with the presumption that the patient has a serious problem. When documenting, ”heart sounds normal, chest clear,” think to yourself – were they really? There is very little routine when it comes to Emergency Medicine and when you think you’ve fallen into one, think again!

4. Review your finances – Ruth Suckling (RMS)

Starting a new post is as good a time as any to take stock of your resources and embrace financial hygiene. Here are some tips: If you have been a flexible trainee make sure your starting increment reflects this extra experience you have gained over the years. For example, if you started speciality/registrar training with a full-time trainee but took two years extra to complete training and reach your CCT date due to being LTFT you should start your consultant post on a year 3 increment. Contact Fleetwood (NHS pensions) to request your pension statement, particularly if you have had many posts at different trusts over your junior doctoring career. You need to ensure all your pension contributions have found their way into your pension pot. Much simpler to iron out hiccups now, thirty (plus!) years before retirement, than in the twelve months leading up to it. Consider your salary sacrifice options. If you have children take the time to ensure you are being ‘tax efficient’ (it’s not like Jimmy Carr – you’re entitled, it’s all above board!) when it comes to childcare costs. Childcare vouchers can be used to pay for nursery fees, after school club and holiday clubs to name but a few. Also investigate other salary sacrifice schemes such as ‘cycle to work’ where you can buy a new bike, and paraphernalia, effectively with a 40% discount. But always be aware of the impact this may have on your pension contributions – if it seems too good to be true, it may well be so.

5. Adopt good email habits – Tom Wiles (TW)

It is likely that you will now send and receive more emails than at any time during your training. When you start, ensure that you are on all the correct email lists (eg. ‘All ED staff’’ ‘ED Consultants’, ‘All Consultants in the Trust’) to ensure that you are kept up to date. After inspiration from the ‘How I work Smarter’ series on the ALiEM blog I have adopted the ‘zero inbox’ approach. This means dividing my inbox into multiple folders where I file received emails that I wish to keep (and delete all the others). I act upon things that need action within 24 hours of receipt and flag up non-urgent tasks that I’ve not done yet. Before doing this, I had accumulated 12 months of emails in my inbox which made identifying important information very difficult!
Since this blog was written, we’ve written a blog just on email management – have a look

6. Family and work (JM & RMS)

Family comes first – always! Be sure to develop a healthy work-life balance. Professional acceptance and pats on the back from work colleagues feel great but cannot replace the love and support of your family. Look after yourself and your household and you will give yourself a head start in becoming a more effective ED clinician. Knowing that some days you will need to collect darling daughter (or any dependent) from school (or other institution), identify those colleagues with whom to nurture an ‘understanding’. The usual risk factors apply: this colleague has kids, a working partner and no extended family to fill the childcare gaps. These individuals are your allies. They understand the quiet desperation of rising blood pressure as your attempts to depart in a timely manner slip away with each new request or emergency which stalks you to the door. They know the challenge of trying to keep all balls in the air, aspiring EM consultant that you are and, more importantly, alpha mum/dad! They also know the look of the child who is the last after school pick-up, not to mention the vibe of the staff who are witness to your clock-strikes-six-screeching-of-brakes arrival. In the real, outside world you are viewed through an unforgiving lens where your tardiness is measured against every other mum, and mitigating factors, such as the number of peri-arrest patients you personally clawed back from the jaws of death, count for nothing. So strike up a reciprocal arrangement which requires no lengthy explanation but simply a mutual understanding and prompt engagement in patient handover so that, sometimes, just sometimes, you’re not the last parent to be at the school gate.

7. Keep the fires burning (WS)

So you’ve passed your exams and have happily put your books away to gather dust. That’s it, you’re done. Don’t fall into this trap. Keep yourself up to date. I am probably preaching to the converted here, but make use of FOAM. There are some terrific sites out there that in a very readable way can quickly put you up to speed on recent developments. If you don’t have time to trawl through the journals, you’ll usually find the important stuff written about on numerous websites. Try to check them out once a week. We owe it to our patients and ourselves to be up to date with developments in EM. Remember, the best way to counter the ‘oh, what did ED do now?’ attitude is to stay razor sharp.

8. Think about changes that can be made Tom Wiles (TW)

The chances are that you will have more recent experience of working in other Emergency Departments than some of your colleagues. Think about good or innovative practices that you can bring to your new ED. Do some research and obtain an idea about costs and other matters before making a proposal to a room full of your senior colleagues. This will help you to answer their questions. It may also be wise to discuss it with the Clinical Director or another senior colleague first as the suggestion that you are making may have been tried unsuccessfully before. They may advise modification before it is worthwhile to try it again.

9. Say no (RR)

You’ll have heard this a thousand times, but learn to say no at an early stage and avoid taking on everything that is thrust upon you. Only take on what you are actually interested in doing so that you’ll do it well. Even then, you should understand your limits, maintain a good work life balance and not take on too much. You can’t change the world in one go and don’t try and achieve ‘everything’ tomorrow. Take one thing at a time, give it your full focus, achieve what you intended and then move on. Be sure to spend your appraisal considering what you’ve achieved, patting yourself on the back and thinking about the extra things you want to take on in the coming year, but ensure that there is always one thing at least that you are also going to give up. Do this because the goals have been achieved, because there can be no further movement forward, because you have lost interest or because you have taken on a new challenge. It’s easy to build and build on your portfolio, but soon you’ll have too much on your plate to give any one thing your best attention and the attention it deserves.

10. Stuff happens (WS)

Every so often you will wish that you had done things differently for a patient but don’t let it beat you down. By all means accept the blow, but use it constructively. Reflect on your practice and strive to improve it. Use the experience to gain an awareness that will help you avoid the same situation in the future. Remember, our job fundamentally boils down to risk management. The only way to fully avoid error is to either admit all the patients you see, or not to see any at all.