Thursday, December 20, 2012

6 Tips to Get Inspired for Burnt Out MDs

palm springs

So, how can you get inspired if you're burnt and crispy?

1. Change your job. Go academic if you're a community doc or vice versa.  Work locums tenens in Australia or New Zealand.

2. Take some time off to recharge. Relax in your favorite country. Maybe someplace where you're currency will stretch much further.

3. Add to your expertise. EMS, U/S, Critical care, or whatever niche you choose

4. Be the change at work.  Try to associate with positive people and avoid negative people.

5. Remember your purpose in being a doctor.  Dig out the files and re-read your medical school application essay, residency program essay, and even college essay.

6. Consider a life coach. Three MD life coaches to check out are: Dr. Heather Fork, Dr. Philippa Kennealy, and Dr. Michelle Mudge-Riley.

Tuesday, December 18, 2012

5 Stages of Physician Burnout

I was reading Dr. Graham Walker's article, Operation Burnout. It made me ponder, why do nearly 70% of emergency physicians feel burnt out?  Even more concerning, ER docs also have the highest burnout rate of ALL specialties.

Burnout is contagious. It's like MRSA and should be called a "staff infection" because it has a tendency to spread.
Ruptured MRSA abscess (via Wikimedia)
Haven't you noticed that when negative people are around you, it has a tendency to bring your energy down as well?

Jerry Edelwich, author of Burnout, writes that there are 5 stages of burnout:

1. Enthusiasm - When you first start the new position, you are super excited and everything is fresh.

2. Stagnation - Things become routine and everything becomes boring.

3. Frustration - By now, the new car smell has worn off and you see the imperfections. The frustration builds at work.

4. Apathy - It feels like you have no power to change anything, and you decide to go with the flow. The longer you stay in this stage, the harder it is to get out.

5. Inspiration - If you're able to get out of apathy, then you realize you can change or change your environment.

Have the courage to be happy and inspired.

Wednesday, December 12, 2012

20 Sacred Rules for Success

  1. Ask
  2. Ask again
  3. Ask again
  4. Ask again
  5. Ask again
  6. Ask again
  7. Ask again
  8. Ask again
  9. Ask again
  10. Ask again
  11. Ask again
  12. Ask again
  13. Ask again
  14. Ask again
  15. Ask again
  16. Ask again
  17. Ask again
  18. Ask again
  19. Ask again
  20. Ask again

Monday, December 10, 2012

10 Tips For Med Students Going Into EM

1.  Join AAEM, EMRA, and ACEP. Free or very inexpensive for medical students.

2.  Go to the annual meetings. AAEM is this Feb, 2013 and in Las Vegas. ACEP is this Oct. 2013 and in Seattle. Attend the medical student components of both conferences.

3.  Get honors in your emergency medicine clerkship.

4.  If you are committed to one program, do an away rotation there.

5.  Check out and listen to these 3 lectures to start:

6.  Go to ACEP's leadership & advocacy conference in May 2013.

7.  Score well on Step 1.

8.  Get a strong letter of reference from at least one emergency physician.

9.  Identify a niche in EM (Ultrasound, EMS, Pediatrics, Hyperbaric, EKGs, Social Media)

10. Seek balance in career, life, health, family, and fun.

What tips do you have?

Wednesday, December 5, 2012

If I could live my life again...

If I could live again my life,
In the next – I’ll try,
- to make more mistakes,
I won’t try to be so perfect,
I’ll be more relaxed,
I’ll be more full – than I am now,
In fact, I’ll take fewer things seriously,
I’ll be less hygienic,
I’ll take more risks,
I’ll take more trips,
I’ll watch more sunsets,
I’ll climb more mountains,
I’ll swim more rivers,
I’ll go to more places – I’ve never been,
I’ll eat more ice creams and less lima beans,
I’ll have more real problems – and less imaginary ones,
I was one of those people who live
prudent and prolific lives -
each minute of his life,
Of course that I had moments of joy – but,
if I could go back I’ll try to have only good moments,
If you don’t know – that’s what life is made of,
Don’t lose the now!
I was one of those who never goes anywhere
without a thermometer,
without a hot-water bottle,
and without an umbrella and without a parachute,
If I could live again – I will travel light,
If I could live again – I’ll try to work bare feet
at the beginning of spring till the end of autumn,
I’ll ride more carts,
I’ll watch more sunrises and play with more children,
If I have the life to live – but now I am 85,
- and I know that I am dying …

Attributed to Jorge Luis Borges

Friday, November 30, 2012

Phraseology for Crucial Communications

It's nice to have a few scripts and templates when talking with others.   Here are a few useful phrases for you to use:

“May I Speak Freely?”

“My purpose in talking with you is …” (a mutual goal)

“When you … I feel . . . ” (action you are giving feedback on – something they can change)

“I imagine that …” (positive intent/benefit of the doubt)

“And because we both want …” (common goal)

“I need …” (specific alternative behavior requested)

Most importantly, affirm him or her as a person

~Dr. Jay Kaplan's Lecture at ACEP Scientific Assembly, Boston 2009.

Wednesday, November 28, 2012

Take Action

I came across this parable, while reading, "Action! Nothing Happens Until Something Moves," by Robert Ringer.

Every morning in Africa, a gazelle wakes up.  It knows that it must run faster than the fastest lion or it will be killed.

Every morning in Africa, a lion wakes up.  It knows that it must run faster than the slowest gazelle or it will starve.

It doesn't matter whether you're a lion or a gazelle; when the sun comes up, you'd better start running.

"Whatever you can do, or dream you can, begin it. Boldness has genius, power and magic in it." ~Goethe 

Monday, November 26, 2012

Non-Medical Advice for Young Emergency Physicians

I was browsing through AAEM's Commonsense Journal (Sept/Oct 2012 Issue PDF) last week and came across a brilliant article by Dr. Andy Walker.  He is a mentor for young EM physicians and offers these points of advice:

Live beneath your means.  Save 15-20% of income if you are employed. Save 25-30% if you are an independent contractor.  Stay out of debt and pay off debt as quickly as possible. EPs should have at least 6 months of income saved, as ER jobs are inherently unstable.  Money may not buy happiness, but it does buy freedom - and freedom is pretty damn good.  Save your money.

Rent, don't own. There will be surprises and you will be in a stronger position if you can pick up and leave.  Especially, rent for the first year.

Insure wisely.  You absolutely need disability insurance, as you are far more likely to become disabled than to die early. Get "own occupation" disability insurance.  If you do get life insurance, get term insurance.  

Be a faithful and disciplined investor.  Start investing early and time will be on your side. Diversify widely. Educate yourself.  He recommends books by John Bogle, the founder of Vanguard. 

Participate in organized medicine. The biggest enemy of physicians is their own sense of hopelessness. But a difficult fight is not an impossible fight. Join your state medical society. Join AAEM today. 

I'd also like to add a couple of things:

Be happy now. You have arrived.  Stop getting trapped in thinking, "I'll be happier, once I get the BMW, house, etc."

Seek balance. Residency can be extreme and now is the time to focus on your health, family, friends, fun, leisure.

Sunday, November 25, 2012

Be Yourself

"Be Yourself," is something frequently said and heard. But to be yourself, you have to know who you are. Take time to reflect on your life and how you came to be where you are right now.

What are your values? What do you want people to say at your funeral? What makes you different?

Wednesday, September 26, 2012

Emergency Haikus

What's causing the pain?
Myocardial infarct.
Transfer to cath lab.

Trouble with sleeping?
Worries and anxiety.
ER is open.

Can't move your right side?
And your speech doesn't make sense?
Head CT and then....

The spider bit you
Redness, swelling, and fever.
Here's doxcycline.

Vaginal bleeding.
What is causing this problem?
Not your period.

Saturday, July 14, 2012

Dr. Raul Ruiz for Congress in 2012

During the CAL/ACEP Scientific Assembly in La Quinta, CA in 2009, Margaret Salmon MD, MPH (a close friend and co-intern) told me, "Sam, you have to meet my friend from Harvard."  This was my first meeting with Raul Ruiz and would not be the last. 

Sometimes, life surprises you with these incidental meetings that seeds the beginnings of life long friendships.  Raul's story is awe-inspiring.  He comes from a family of immigrant farm workers from the Coachella Valley desert.  To get into college, he went to his neighbors' doors and made a promise, "Help me pay for college.  I promise to come back here and make a difference."

Not only did he make it to college, but he went to Harvard and graduated with three degrees (MD, MPH, MPP).  Afterwards, he went on to complete an emergency medicine residency and an international medicine fellowship.

Now, he is a community ER doctor back in the Coachella Valley desert and Associate Dean at the University of Riverside School of Medicine.  He made a promise many years ago and kept it.

When Raul told me he was running for Congress, it just made sense to me.  He is the kind of leader that I want to see helping create laws and addressing disparities.  Raul is an emergency doctor who has the back ground in public health and public policy tools to make a positive impact.

Would you like to see someone who understands medicine, policy, and public health to help create legislation?

Do you want to have someone in Congress who keeps his promises?

Please make a donation to Dr. Raul Ruiz.  Even $5 makes a difference in this grassroots campaign. Here's the link: 

Raul Ruiz, MD, MPH, MPP

Friday, June 29, 2012

International Ultrasound Resources

By Dr. Sachita Shah

BOOKS : Obviously there are many within our specialty, but these are
some ultrasound books outside of EM that have pertinent info for
practice in low resource settings and/or are written for generalist
health care providers

1) Cristoph Dietrich, MD, and colleagues have published a freely
downloadable, online full color textbook, including special chapters
on US in HIV and tropical diseases. It is an in depth resource that is
made more for experienced clinician-sonographers, and written in high
level /technical english. Great work and so inspiring that it is free!
Please check it out at this link:

2) Ultrasound: A Practical Approach by William Marks.

3) Training in Diagnostic Ultrasound Essentials, Principles and
Standards, WHO Study Group report.

4) Manual of Diagnostic Ultrasound in Infectious Tropical Disease
(covers abdomen only, available by amazon too)

5) Partners In Health Manual of Ultrasound for Resource Limited
Settings (free, electronic book in pdf, simple english, point-of-care
approach to abd/ob/dvt/skin/procedures etc)

1)  Short Course on Abdominal Ultrasound in Tropical Disease
This course  (YEARLY, April, Italy)is designed for clinicians who wish
to acquire basic skills in ultrasound of the abdomen and a general
overview of Ultrasound in Tropical Medicine. Imaging specialists who
want to acquire knowledge in the field of Infectious Diseases and
Tropical Medicine can benefit from this course as well. It is also
designed for MDs who plan to work in tropical/resource poor areas or
who are already experienced in field work but need to refine their
skills in this diagnostic tool.

2) Clinical Ultrasound in Tropical Infectious Diseases
Join the faculty of the Instituto de Medicina Tropical, Alexander von
Humboldt, Cayetano Heredia, Lima, Peru; the Center of Operational
Medicine, Section of Clinical Ultrasound, Georgia Health Sciences
University; and the University of Pavia, Division of Infectious and
Tropical Diseases, IRCCS S. Matteo Hospital Foundation as they co-host
the first Clinical Ultrasound in Tropical Infectious Diseases course
in Lima, Peru, October 21-26, 2012. Providers with experience and/or a
special interest in clinical tropical medicine or infectious disease
with ultrasound experience are invited to attend. This unique course
consists of lectures, demonstrations, and small-group clinical rounds
for live ultrasound scanning.

Dr. Sachita Shah is Assistant Professor at UW Division of Emergency Medicine in Seattle.  She completed her US fellowship at Alameda County Medical Center-Highland Hospital.  She is the first author of "The Partners in Health Manual of Ultrasound for Resources Limited Resources." (See the link in number 5 above)

Thursday, June 28, 2012

Intro to Social Media for Newbie MDs

Have you ever Googled your name to find or as the main link to your professional face online?

What hurts even more is when you have a one out of four star rating by an anonymous person. 

Today, you will learn three places to get started in social media. Go to LinkedIn and create a profile. This is free. Put up a professional picture online and parts of your CV.  Remember, this is the internet and everything your put up in now public.  So, no social security or DEA numbers. Create a twitter account with your real name and another professional picture.  Do some searching on twitter.  Find other MDs, RNs, Med students, PharmDs, etc to follow.   Tweet useful links, thoughts, comments, & questions. Again, remember this is on the World Wide Web so imagine everything you put up will be published in the NYTimes Sunday Edition. or  Create a blog.  A blog is shortened for weblog.  It’s an online journal, but not everyone wants to hear about what you had for dinner or who you have a crush on.  Write short articles on health related topics.  Nothing that violates HIPPA or patient confidentiality.  Use lots of pictures.

Be fairly diligent in the above activities, maybe 1-2 posts/tweets per week.  Wait 6 months and do a google search with your name.  You will see a difference!  

Tuesday, April 17, 2012

Meditation for Physicians

When stepping into a new patient's room, I must clear my mind completely.  To make a diagnosis, it's crucial to listen with 100% attention.  If I think about the patient I saw before, or what lab result I need to look up, my focus becomes divided.  One way to be more aware of the present moment is through meditation practice.

During medical school, Jon Kabat-Zinn lectured at the U. of Rochester and led us through various awareness exercises.  One exercise was to eat a raisin very s - l - o - w - l - y, savoring the taste and texture.  I still remember how potent the single raisin tasted.

Now, I've re-discovered him on the EM Tutorials Podcast  (By Drs Chris Cresswell, Qasim Alam and Andrew Dean-Ballarat, Australia and New Zealand)

I highly recommend you download # 7 Breath Meditation and give it a try for a week.  It's also FREE.

Monday, April 9, 2012


Once you've identified the time each patient spends at a certain step, you can identify which takes the longest.

NOW, you have identified the bottleneck.

Everything is dependent upon this bottleneck.  Recall the rate limiting step (RLS) in chemistry.  This step is typically a catalyst or rare substrate.  It's the process that S - L - O - W - S  everything else down.  In the ED, this may be: time to get a lab report, a 5150 bed, or the the on-call dialysis nurse.

Use a multi-perspective approach by including RNs, Techs, ICU docs, etc. to reduce the time it takes in the slowest step.  This can be challenging, but will reap huge rewards.

Lather, rinse, & repeat.

Monday, April 2, 2012

What are the important things to measure for ED flow improvement?

There are many metrics in the ED, ranging from patient satisfaction to % of Medicaid patients.   To improve patient flow and identify bottlenecks, there are 10 steps and times that should be measured:

1. Door to Triage
2. Triage to MD (assuming MD is in triage)
3. Bed to RN
4. Bed to MD
5. MD to Decision (DC vs. ADMIT)
   6) Imaging order to read
   7) Lab order to results
   8) Recheck of patient
9) DC to actually being out of ED
10) ADMIT to floor

If you add the total time of each of these steps, this equals total Length of Stay in ED (LOS).

Based upon the review of the time needed for each of step, an ED director can determine which areas need more effort and time to reduce the time in ED.  This is crucial because patient satisfaction is linked to the overall time in ED. 

Monday, March 26, 2012

Little's Law Applied to the ER

Little's Law is a fundamental equation in operations. It's like F = m*a to physics and CO=HR*SV to critical care.

Applying it in the ED, Little's law states:

Number of patients in ED = Arrival rate of patients/hr * Avg length of stay in ED/Pt

Two of these numbers are readily available. Number of pts in ED and the arrival rate.

For example, lets assume that the ED bed capacity is 50 beds and normally has 40 beds occupied at a given time. The arrival rate on an average day is 10 pts/hr. What is the average length of stay in the ED?

Avg length of stay = # of pts in ED / arrival rate

= 40 pts / (10pts/hr)

= 4 hrs

Based upon this, we can figure out average LOS in ED and work on factors to decrease total ED length of stay for patients.

* More on Little's Law (pdf)

Thursday, March 1, 2012

The CPR Game for iPhones

Last night, I was hunting for new apps on my iPhone 4s and came across this gem.

I only have the Lite version, but I was entranced into playing for hours.  Its comparable to being in a tiny Tetris Sim center

In this game, your goal is to resuscitate the old, young, and very sick.  A nice touch is the option to use the cardiac and FAST ultrasound while running the code.

The complete version is $1.99, a very tolerable price.   Enjoy!