EDITOPdALS Residency Training: The Missing Curriculum This communication has been germinating for m a n y years and reflects m y observations as a practicing emergency physician, teacher, American Board of Emergency Medicine (ABEM) examiner, academic department chairman, and director of a busy (50,000 patients a year) private hospital emergency department. I believe that our residencies have reached the point where an excellent command of the knowledge and skills of our specialty should come with every graduate. With the advent of three- and fouryear programs, there appears to be time to focus on such issues. My hope is that residency directors emphasize this information and residents recognize its importance. Emergency medicine graduates are expected to have broad knowledge and provide quality care; board certification is the m i n i m u m standard. Yet, when successful residents fail in the real world, it rarely is a deficit in knowledge or intelligence. Many good physicians move from one unsatisfactory performance to another in private practice until they acquire the other skills necessary for survival or find a less-demanding position. They, however, should not have to learn these skills on their own. Most emergency medicine practice occurs in an environment completely unlike our training programs. Of the approximately 5,000 EDs in the United States, probably less than 200 resemble teaching centers. Graduates need special skills to function in the others. They must be adequately prepared for this much different milieu to be useful, m a r k e t a b l e , employable, and h a p p y in the "real world" of community hospital emergency care. Teaching programs readily change to meet the needs of the Residency Review Committee; ABEM; and the academic requirements, peculiarities, and politics of the sponsoring institution. Modifications on behalf of future employers, coworkers, medical personnel, and p a t i e n t s also are needed. Residents should be trained to do as well in the nonacademic world as they do on the boards. The good jobs (professionally challenging and professionally and financially rewarding) go to the person with more than the highest ABEM scores or the broadest knowledge base. Academic faculties must contain those who can convey such information with credibility.
THE MISSING CURRICULUM Patient Relations A genuine sensitivity to others is the key to good relations with patients, but the behavioral skills that are involved in c o m m u n i c a t i n g such characteristics can be taught, refined, and practiced. Like it or not, emergency medicine is a business that depends on patient (customer) satisfaction, repeat business, and word-of-mouth referral. Their physician's attitude makes a bigger impression on m o s t patients than medical knowledge or procedural skills. There is therapeutic value to having your patients like you: they are much more likely to follow recommendations, fill prescriptions, and return to your ED if their illness or injury does not improve. While significant to ev19:1 January 1990
ery specialty of medicine, communication, behavioral, and social skills are even more crucial to emergency medicine because our working relationship and rapport with (often unwilling) patients must be established during such brief, intense, and often uncomfortable interactions. In emergency medicine, the individual physician's behavior reflects on all who work in that ED. The number of complaints about the "cold" approach of certain physicians far outnumbers questions about the quality of their care. Teach the skills; teach physicians to look the patient in the eye, to answer all questions (spoken and unspoken), to touch, and to communicate in language the patient can understand. By all means, school your residents in the differential diagnosis of childhood fevers; then, teach them to explain it to the worried new mother in a way that will cause her to say, "Thank yon. Do you have a private office?" They must know that the product of an encounter should not be just Hx, PE, Dx, Rx; it should be satisfied and informed patients and families. It is not over when the prescription is written. Take a page from the successful pediatrician: The 2-year-old is not your only patient.
WORKING WITH OTHER HEALTH PROFESSIONALS Private Physicians The patients' physicians know their people and their illnesses. The private physician should be consulted, participate in referrals, and get the patients back when the ED evaluation is over or hospitalization is required. There is an art to the concise telephone report, often one's only contact with some physicians: private physicians want to know what is wrong with their patient, the emergency physician's recommendations, and how soon they should see their patient. Teach physicians how to disagree nicely when necessary; it is not enough to be right. Too many angry attendings, and one is out of a job. Graduates must have the communication skills to extract what the patient needs (eg, hospitalization, consultation, early evaluation). Teach them how to reward the "good" consultants. Medicolegal considerations aside, sometimes it is in the best interest of the patient for your student to write orders (ie, when the attending obviously is not grasping the situation, whether due to fatigue or it's being 3:00 AM; w h e n there are special skills required, such as overdose management; or when you are asking a favor in admitting the patient, called "social" admissions). Emergency physicians spend an enormous amount of time on the telephone. The capacity to give, receive, and docum e n t communications should be an important part of their training.
Coworkers Worldng comfortably with fellow emergency physicians is a skill that must be acquired. Coming a little early for shifts, sharing the more interesting cases, and working to capacity until it is time to leave are likely to promote
Annals of Emergency Medicine
95/153
EDITORIALS
similiar behaviors in colleagues.
Paramedics It is fine to teach prehospital care in the curriculum, but be sure to add a section on "how to make the paramedics come to you." Treat them with respect and professionalism, let them know you value their knowledge and skills, correct errors tactfully and out of the hearing of others, praise their successes; that is, nurture a rapport. It goes without saying that emergency medicine graduates must participate in continuing education of paramedics and in the local emergency medical services system.
colegal risks of leaving the ED for a code on the floor or in intensive care are obvious, but it is a rare hospital without house staff in which that is not the emergency physician's responsibility. While we are working to change this, we must be taught how to deal with it. Private patients will not wait forever. From 3.0 to 3.3 patients per hour is considered a good pace for patient care, patient flow, and reimbursement. That average means caring for as many as five or six per hour at busy times. We should study the art of moving patients through a busy ED with good care and patient satisfaction.
Financial Management VIPs The recognition, care, and feeding of the VIP is one of the hardest "real world" lessons for the neophyte emergency physician to assimilate. Continued employment often depends on the goodwill of more than the patient. Other key players include administrators, nursing supervisors, members of the board, the ED director, private physicians (especially those who admit frequently), and relatives, friends, and lovers of the "powerful," all of whom can make one's life miserable. On occasion, it comes to a choice of keeping one's egalitarian principles or one's job. The competent emergency physician can learn to make the VIP feel like one without compromising the care of others.
Too many recent graduates get their first (unhappy) lessons in the realities and intricacies of retirement plans; estimated taxes; and life, health, and disability insurance in April of the year after they enter private practice.
Community Relations It is the task of the newest members of our specialty to build the credibility that the image of the moonlighting, part-time emergency physician has often denied us. We must recognize the responsibility to become part of both the general and medical communities in which we live. Participation in medical personnel social and administrative functions, medical societies, and community service is necessary before we can take our places beside our colleagues with office-based practices.
Nurses Graduates must know how to work well with the nurses and truly understand their importance. Teach them how to win respect and affection, to honor the nurses' input, and to come when the nurse calls. Help them to educate without pontificating and to explain when their management differs from that to which the nurses are used. Nurses can make the job of caring for ten patients easy or the task of tending two patients impossible. They can build or shatter a young physician's image or self-confidence.
Efficiency and Patient Flow Realize that there is no emergency practice more unnatural than the teaching hospital. All that help! The emergency physician in private practice spends a significant amount of the day as the only physician in the hospital. In the c o m m u n i t y hospital, multiple ill patients must be cared for simultaneously without neglecting the routine. This is the essence of emergency medicine practice, and the skills required to do this must be actively studied and reinforced. One ill patient cannot monopolize all of the physician's time. Residents must leave training with the visceral awareness that there will most likely not be an ED attending, surgical resident, cardiology fellow, gynecologist, or anesthesiologist down the hall. The average patient they admit will not be seen for a while, so ensuring stability is crucial. One cannot get on the phone and demand (as so many candidates do during the board examination) that the surgeon appear instantly when summoned. The medi154/96
Flexibility and Self-Education New graduates must be flexible. When you show them the "right" way (generally the way you and your institu o tion have been doing "it" for a while), help them to understand that other techniques also are acceptable. Have them critically examine alternatives before dismissing them out-of-hand or criticizing them when taken by others. Finally, when residents leave your program, help them recognize that they will not know it all. Teach them not to act as if they do. Let them leave with an open m i n d so that every day of their emergency medicine career is a new learning experience and every patient is a challenge in human relations as well as in diagnosis and treatment. Give them the skills, habits, and self-motivation that will allow them to continue to learn and grow throughout their careers.
The author gratefully acknowledges the contributions of the following individuals to the final form of this editorial: Steven C Dronen, MD, FACEP; Leonard Checchio, MD; Carey D Chisholm, MD, FACEP; Steven J Davidson, MD, FACEP; Bernardine Frumkin; Glenn C Hamilton, MD, FACEP; and Richard M Nowak, MD, FACEP.
Kenneth Frumk~n, PhD, MD, FACEP Las Vegas, Nevada
Annals of Emergency Medicine
19:1 January 1990
THE MISSING CURRICULUM Patient Relations A genuine sensitivity to others is the key to good relations with patients, but the behavioral skills that are involved in c o m m u n i c a t i n g such characteristics can be taught, refined, and practiced. Like it or not, emergency medicine is a business that depends on patient (customer) satisfaction, repeat business, and word-of-mouth referral. Their physician's attitude makes a bigger impression on m o s t patients than medical knowledge or procedural skills. There is therapeutic value to having your patients like you: they are much more likely to follow recommendations, fill prescriptions, and return to your ED if their illness or injury does not improve. While significant to ev19:1 January 1990
ery specialty of medicine, communication, behavioral, and social skills are even more crucial to emergency medicine because our working relationship and rapport with (often unwilling) patients must be established during such brief, intense, and often uncomfortable interactions. In emergency medicine, the individual physician's behavior reflects on all who work in that ED. The number of complaints about the "cold" approach of certain physicians far outnumbers questions about the quality of their care. Teach the skills; teach physicians to look the patient in the eye, to answer all questions (spoken and unspoken), to touch, and to communicate in language the patient can understand. By all means, school your residents in the differential diagnosis of childhood fevers; then, teach them to explain it to the worried new mother in a way that will cause her to say, "Thank yon. Do you have a private office?" They must know that the product of an encounter should not be just Hx, PE, Dx, Rx; it should be satisfied and informed patients and families. It is not over when the prescription is written. Take a page from the successful pediatrician: The 2-year-old is not your only patient.
WORKING WITH OTHER HEALTH PROFESSIONALS Private Physicians The patients' physicians know their people and their illnesses. The private physician should be consulted, participate in referrals, and get the patients back when the ED evaluation is over or hospitalization is required. There is an art to the concise telephone report, often one's only contact with some physicians: private physicians want to know what is wrong with their patient, the emergency physician's recommendations, and how soon they should see their patient. Teach physicians how to disagree nicely when necessary; it is not enough to be right. Too many angry attendings, and one is out of a job. Graduates must have the communication skills to extract what the patient needs (eg, hospitalization, consultation, early evaluation). Teach them how to reward the "good" consultants. Medicolegal considerations aside, sometimes it is in the best interest of the patient for your student to write orders (ie, when the attending obviously is not grasping the situation, whether due to fatigue or it's being 3:00 AM; w h e n there are special skills required, such as overdose management; or when you are asking a favor in admitting the patient, called "social" admissions). Emergency physicians spend an enormous amount of time on the telephone. The capacity to give, receive, and docum e n t communications should be an important part of their training.
Coworkers Worldng comfortably with fellow emergency physicians is a skill that must be acquired. Coming a little early for shifts, sharing the more interesting cases, and working to capacity until it is time to leave are likely to promote
Annals of Emergency Medicine
95/153
EDITORIALS
similiar behaviors in colleagues.
Paramedics It is fine to teach prehospital care in the curriculum, but be sure to add a section on "how to make the paramedics come to you." Treat them with respect and professionalism, let them know you value their knowledge and skills, correct errors tactfully and out of the hearing of others, praise their successes; that is, nurture a rapport. It goes without saying that emergency medicine graduates must participate in continuing education of paramedics and in the local emergency medical services system.
colegal risks of leaving the ED for a code on the floor or in intensive care are obvious, but it is a rare hospital without house staff in which that is not the emergency physician's responsibility. While we are working to change this, we must be taught how to deal with it. Private patients will not wait forever. From 3.0 to 3.3 patients per hour is considered a good pace for patient care, patient flow, and reimbursement. That average means caring for as many as five or six per hour at busy times. We should study the art of moving patients through a busy ED with good care and patient satisfaction.
Financial Management VIPs The recognition, care, and feeding of the VIP is one of the hardest "real world" lessons for the neophyte emergency physician to assimilate. Continued employment often depends on the goodwill of more than the patient. Other key players include administrators, nursing supervisors, members of the board, the ED director, private physicians (especially those who admit frequently), and relatives, friends, and lovers of the "powerful," all of whom can make one's life miserable. On occasion, it comes to a choice of keeping one's egalitarian principles or one's job. The competent emergency physician can learn to make the VIP feel like one without compromising the care of others.
Too many recent graduates get their first (unhappy) lessons in the realities and intricacies of retirement plans; estimated taxes; and life, health, and disability insurance in April of the year after they enter private practice.
Community Relations It is the task of the newest members of our specialty to build the credibility that the image of the moonlighting, part-time emergency physician has often denied us. We must recognize the responsibility to become part of both the general and medical communities in which we live. Participation in medical personnel social and administrative functions, medical societies, and community service is necessary before we can take our places beside our colleagues with office-based practices.
Nurses Graduates must know how to work well with the nurses and truly understand their importance. Teach them how to win respect and affection, to honor the nurses' input, and to come when the nurse calls. Help them to educate without pontificating and to explain when their management differs from that to which the nurses are used. Nurses can make the job of caring for ten patients easy or the task of tending two patients impossible. They can build or shatter a young physician's image or self-confidence.
Efficiency and Patient Flow Realize that there is no emergency practice more unnatural than the teaching hospital. All that help! The emergency physician in private practice spends a significant amount of the day as the only physician in the hospital. In the c o m m u n i t y hospital, multiple ill patients must be cared for simultaneously without neglecting the routine. This is the essence of emergency medicine practice, and the skills required to do this must be actively studied and reinforced. One ill patient cannot monopolize all of the physician's time. Residents must leave training with the visceral awareness that there will most likely not be an ED attending, surgical resident, cardiology fellow, gynecologist, or anesthesiologist down the hall. The average patient they admit will not be seen for a while, so ensuring stability is crucial. One cannot get on the phone and demand (as so many candidates do during the board examination) that the surgeon appear instantly when summoned. The medi154/96
Flexibility and Self-Education New graduates must be flexible. When you show them the "right" way (generally the way you and your institu o tion have been doing "it" for a while), help them to understand that other techniques also are acceptable. Have them critically examine alternatives before dismissing them out-of-hand or criticizing them when taken by others. Finally, when residents leave your program, help them recognize that they will not know it all. Teach them not to act as if they do. Let them leave with an open m i n d so that every day of their emergency medicine career is a new learning experience and every patient is a challenge in human relations as well as in diagnosis and treatment. Give them the skills, habits, and self-motivation that will allow them to continue to learn and grow throughout their careers.
The author gratefully acknowledges the contributions of the following individuals to the final form of this editorial: Steven C Dronen, MD, FACEP; Leonard Checchio, MD; Carey D Chisholm, MD, FACEP; Steven J Davidson, MD, FACEP; Bernardine Frumkin; Glenn C Hamilton, MD, FACEP; and Richard M Nowak, MD, FACEP.
Kenneth Frumk~n, PhD, MD, FACEP Las Vegas, Nevada
Annals of Emergency Medicine
19:1 January 1990
