I am Dr. Daniel Lakoff, Associate Residency Director: How I Promote Wellness in EM

Promoting wellness is a team sport. It takes more than one individual to champion it at any institution. In medicine, when a team is formed to effect change, it is called a committee. Dr. Dan Lakoff was one of the founding leaders of the council of residency wellness committee, and has also helped lead wellness efforts at his own institution. Here he shares his thoughts, his inspiration, and practical ideas that helped improve wellness at his program.

Name Daniel Lakoff, MD, FACEP daniel lakoff
Location Icahn School of Medicine at Mount Sinai, New York, NY
Current Job  Attending Physician, Associate Residency Director

How did you become interested in wellness and resilience?

I became interested in the topic of wellness and resilience by witnessing and experiencing the paradox of medicine: where physicians are being held to high standards charged with the care of patients, but are not caring for themselves. For centuries a physician’s skill has been measured in lives saved, suffering eased, human kindness, and prowess in teaching. Now we are simply and bluntly being measured by metrics and profitability. This transformation of values has led to profound discontent, as we’ve been asked to play a game treating numbers and not people. My goal is to work with like-minded individuals to help effect culture change so that we include physician satisfaction in the equation of what makes a department and hospital work well.

What resilience and wellness initiative have you started? What is your role?

I have been fortunate to have be surrounded by great colleagues who have provided support and helped nurture ideas. I have part of the team that has helped transform our Wellness program at Mount Sinai from one based on social events to one with a meaningful educational structure and support network.  I am also co-chair of a newly formed GME Wellness subcommittee at my institution and a co-chair of the CORD (Council of Residency Directors) Resilience Committee where we are aiming to find ways to share ideas to improve residency wellness nationally. Specific changes implemented include the following:

Lecture series: The overarching plan is to have a 24 month curriculum and lecture series. This year our Wellness Committee residents took on the task of being the lecturers for near-peer teaching. In lectures we discussed topics such as impostor syndrome, sleep, and debriefing. We have also tried round table discussions and free writes, and have plans to do more small group discussions and resilience training next year.

Surveys on Wellness and Resilience: Just as we are taught that the plural of anecdote does not equal data, we were faced with the reality that no institutional change can occur without data. In light of this, we have implemented the use of the Maslach Burnout Inventory (MBI) as a means to measure residency wellness. Though we are still considering alternative tools, the MBI has definitely proven useful to shed light on the current mood of our residency and support our wellness movement.

Wellness month: After one attempt at a wellness week, it was obvious that we not able to include all our residents in the events due to the complexity of our academic schedules, so we morphed our wellness week into a wellness month. We scheduled it right after the winter holidays during the dreaded “Block 8” when the cold and dark of a Northeastern winter hits the hardest. During that month, we hosted a set of 4 bolstered “Tuesday Night Fun” or “TNF” events, and also scheduled events on Wednesdays post-conference. Examples of “TNF” events from the past year included: attending a movie as a group, an excursion to a trendy bar with some activities (shuffleboard), a “whine and cheese”. Examples of post-Wednesday conference events were: a spa trip, a yoga session, spending time with puppies, and a ski trip. Our conferences themselves had a few wellness-related lectures and small group sessions as well.

Sports Series: One other highlight for our program is our resident-vs-attending sports series in which we have organized three games over the course of the year with softball, basketball, and touch football. It has been a great way to get faculty and residents together outside of our typical confines and has lead to some great stories and camaraderie.

What has been the outcome or result of your initiatives?

At the departmental level, I think our residents see that we care about their wellbeing as well as their education. At the GME level, we have been able to move our agenda forward of making residency more “live-able”, not just a time of life that needs to be survived. Nationally at CORD, we have made great progress on a few fronts, but I think as a specialty and physicians, the efforts to fight burnout are about to catch fire (no pun intended)!

What hurdles have you had to overcome?

With the current tidal wave of interest in the subject and mounting discourse right now, I have been fortunate in that I have not run into any major hurdles.

Where have you found support?

At the program-level, we have obtained support from all important and involved parties in the equation, from our graduate medical education (GME) office, chairman, and program director. Nationally, the council of residency directors (CORD) leadership and membership has been extraordinarily supportive of our endeavors on the resilience committee.

What do you see as most important for promoting wellness in your program?

The first and most important step is that we had to re-brand, broaden, and reframe the meaning of “wellness” at our program. It went from simply meaning social gatherings (usually involving alcohol) to a legitimate academic focus. The next few critical steps that added legitimacy to our wellness committee were to build a solid team, define what “wellness” meant to us and our program, and finally put pen to paper to create the wellness curriculum and academic calendar.

What would you recommend as important, practical steps that individuals at other institutions could take?

  1. Build enthusiasm for your wellness program by building an awesome team of like-minded attendings and residents.
  2. Identify all current practices that are wellness-related and claim them as wellness initiatives, with plans to bolster or infuse them with some educational concepts and integrate them with the wellness curriculum as a whole.
  3. Start developing a strategy for a longitudinal curriculum to ensure spaced-repetition of wellness education
  4. Try to change the climate at your institution as a whole by engaging the GME with the concept of resident wellness
  5. Ensure your team is rewarded for their hard work with positivity and opportunities for career growth.

 

 

Author information

Christina Shenvi, MD PhD

ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina
www.gempodcast.com

The post I am Dr. Daniel Lakoff, Associate Residency Director: How I Promote Wellness in EM appeared first on ALiEM.

10 Tips on How to Succeed Your First Year Out After Residency Graduation

If you are graduating from an EM residency this year, you may be feeling nervous (or petrified) about your first shift out on your own. You’re wondering how you can gain the trust of the nurses and doctors at your new hospital. Perhaps you are wondering how you will keep learning without the residency leadership forcing articles and lectures on you.

In this post we will give you our top 10 tips, each with a practical pearl, for how to succeed your first year out. These keys to success will help keep you from making common mistakes, blowing your chance at a good first impression, and also help keep you out of deep, troubled waters when it comes to HIPAA violations and keeping your medical license.

Tip 10. Set Goals and Find Mentors

You’ve probably been told at some point that you should write down your 5-year and 10-year goals. If you haven’t been told that, then we’re telling you now! If you do not have your goals in mind, then it is easy to get drawn down tracks that you are not truly interested in. For most of the last decade, the majority of your decisions have been laid out for you to make. The necessary steps have been mapped out neatly for you: MCAT, medical school applications, USMLEs, and the match.

Now that you have graduated, the world is wide open. You could develop a niche in ultrasound if you want, become a department administrator, develop your teaching skills, or start writing. In order to pick the right opportunities, you have to know where you want to go in the future. Unfortunately if you do not set your path towards your goals, you can find that in 5 or 10 years, you are not where you wanted to be or have not achieved what you had hoped.

As a practical step, we recommend that you sit down and think through your 5- and 10- year goals, and write down what you need to do to get there. It’s a great idea to talk to one of your faculty mentors or residency leadership about how you can attain those goals. Is it to be in a specific leadership position? To speak at ACEP? Your faculty members who have done these things can tell you how to get there.

Tip 9. Play Well With Others

You are probably moving to a new “sandbox” after graduation where you will need to make new friends. That includes both socially and professionally. Start at work. Talk to people: co-workers, nurses, technicians, consultants, janitors, staff, etc. Make eye contact and smile at people in the hallways. Be sure to introduce yourself. This will be easier to do when you can say “Nice to meet you. I’m the new guy (or gal)!” rather than months or even years after you start. We all know that awkward moment when you talk people you SHOULD know but never really met or learned their name. Consults and admissions will be so much easier when the person on the phone is a friend, rather than a stranger. You might even find out you have common interests outside of work, like family or hobbies, and begin a social friendship.

Tip 8. QI Yourself (Quality Improvement)

During residency, you have had an attending looking (or lurking) over your shoulder every minute! They have given you big and small pieces of feedback to help guide your medical thinking, your procedures, and teach you how to run an ED. Now that you are on your own, you will need to do that for yourself. Practically, that means thinking about and reflecting on how you are doing. If a code went particularly smoothly, figure out what it was that made the communication tight and the teamwork on point. If something did not go well, it is even more critical, but also more painful, to reflect on what happened. Figure out what you could do better in the future to make sure you are constantly improving.

It is generally believed that you are not an expert emergency physician until about 5 years out of residency, so keep self-reflecting on your practice. Did you miss a subtle STEMI on an ECG? Spend some time reviewing ECGs. Take a course on it. Read some books on ECGs. Did you flounder running a code? Ask for honest feedback from your nurses. Look for simulation opportunities to practice your skills. Run through scenarios with a friend who can give you honest, thoughtful feedback. Practice and rehearse what you will do next time a coding patient presents via ambulance.

Using deliberate practice in this way, you can turn your past failures into future successes. If you do not do this, then your skills will atrophy rather than grow, and you could find yourself having practiced for 20 years but with skills no better than a senior resident.

Tip 7: Get Your Paperwork Done on Time

Soon you won’t have your amazing residency coordinator sending you 15 reminders while beating you over the head to get that boring, painful stuff done. Charts, licensing requirements, and hospital modules are all necessary parts of keeping your job. The paperwork is not as glorious or rewarding as saving lives, but it is important and generally easy. Do not end up on the naughty list with hospital administration for simple, albeit tedious, tasks. So, get your charts done on time. Respond to emails in a timely manner. Be polite and grateful to support staff and they will make your life easier.

Tip 6: Keep Learning and Stay Humble

During your career you will not only have to relearn all the things that you are continuously forgetting, but you will also have to learn completely new things. For example in the last 5 years, novel oral anticoagulants (NOACs) and other entirely new classes of medications are now available. Physicians need to learn how their indications, doses, and their complications. Physicians who graduated 20 years ago probably did not know a linear from a phased array ultrasound probe. In order to stay current, you too will continually have to learn new skills and treatments. Thus remain open to and pro-active about learning new things.

During residency you have had learning forced on you with lectures, required journal clubs, podcast assignments, and the in-training exam. Now that you are on your own, you have to motivate yourself to learn. Practically, this means planning time to read and choosing some high quality resources. Picking a few high profile journals or articles a month is a good place to start. However, no one can stay up to date on all the journal articles, so it is a good idea to pick secondary sources (such as blogs or podcasts) as well. Keep up your subscriptions to the EM journals, podcasts, or online resources that you liked during residency. If your program or hospital does not already have a journal club, consider starting one. If no one else is interested in a journal club, then pick one of your residency buddies, read the same things, and discuss them to keep each other accountable. Peer pressure and the fear of looking incompetent are great motivators.

It is also important to stay humble. There will always be more for you to learn, and there will always be syndromes, complications, and diseases that you have never heard of. So never become too proud to learn from your colleagues, consultants, nurses, and your patients.

Tip 5: Discharge Abnormal Vital Signs with Caution

Not to say that you can NOT discharge these patients, but do it only after you have really thought about what you are doing. Use it as a self-check to re-run your differential diagnoses and treatment plan. For example, your internal dialogue may be:

Good example: “The patient in room 5 can go home with atypical chest pain because they can’t have a PE since they are PERC negative…oh wait… their heart rate is 115…so I can’t use the PERC rule… let me re-think this…”

Bad example: ”I am OK with room 10  going home with a HR of 110 because I know they have missed their beta blocker today and probably just have reflex tachycardia.”

Tip 4: Respect the Things that Can Get You Fired

Nothing will get you fired faster than a social media HIPAA violation. While a post on your “closed” Facebook group may seem innocuous, hilarious, or educational, it is extremely important that you never include any identifying information. While 99.9% of the Facebook group may share your sentiment, or may even appreciate the educational point you are making, your department chair may also be a part of the group and may not appreciate it. Or a disgruntled or even a well-meaning colleague may report it to your institutional privacy office. Being investigated by your privacy office or by your state medical board is no way to start out a new job. So be extremely cautious.

Also, don’t be reckless. Do not post pictures of yourself drunk online! Do not drink and drive! If you have a DUI, you will have to report it every year when you apply for your medical license renewal and every time you apply for a new job. For jobs in highly competitive areas, you will not want any red flags on your application, even if you are an otherwise fantastic clinician.

Tip 3: Follow Your Gut

You have studied and worked hard for countless hours in identifying sick and not sick over the past 3-4 years. You have seen thousands of patients and have begun to develop a 6th sense, or a “gut feeling”. If your gut tells you something isn’t right, listen to it. When the x-ray looks odd to your trained eye despite the radiologist’s negative read, listen to your gut and follow through. If your gut gets queasy at the thought of discharging the 2.5-month-old with a fever or the 95-year-old lady with a fall, listen to your gut and keep them for observation. Your gut is well-trained and usually right.

Tip 2: Do Not Feel Bad About Ordering or Admitting More

While following your gut will work most of the time, sometimes it is a struggle to clearly identify the underlying problem or diagnosis. So if you are in doubt about admitting a patient or ordering a CT scan, do it. Do not feel bad about having higher rates of admission or testing than the clinicians who have been practicing clinically for 10-20 years. It is expected that you will be more conservative initially. If you do find yourself worrying after you discharged a patient or are concerned that you missed something, do not forget that you can just pick up the phone and call them! Patients love having their doctor call them to check on them, and it provides a chance for you to allay your worries, reassess their condition, make sure they picked up the prescription you sent, and reiterate when they need to return to the ED.

Tip 1: If You Hate Your Job, Leave It!

About 50% of emergency physicians change jobs within their first 2 years of out residency. There is no reason to continue and persevere in a job you hate. You are not a failure for leaving a job. Many of us do not know exactly what kind of practice is right for us immediately post-residency. We do not know the right questions to ask when interviewing or signing a contract. Luckily, the opportunities for emergency physicians are endless and diverse. You can find a better job fit for you. Not leaving may be the one thing keeping you from your ideal job, happiness, and success.

A Caution and a Benediction

You can practice anywhere in the world, master any sub-specialty from deep sea medicine to aeronautic medicine and everything in between. You will find that the greatest challenge is not the actual medicine but in maintaining your humility, altruism, optimism, kindness, and grace in the face of limited resources, tragic outcomes, a chaotic environment, and a system that often works against rather than for the patient.

We hope that as you graduate you will find patients who inspire you, co-workers who support you, and mentors who help guide you towards a long and fulfilling career in Emergency Medicine!

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Author information

Christina Shenvi, MD PhD

ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina
www.gempodcast.com

The post 10 Tips on How to Succeed Your First Year Out After Residency Graduation appeared first on ALiEM.

60 Second Soapbox: Shared Decision Making, Backboards, and Caring for the Family

60 second soapboxIts’ time for another installment of 60 Second Soapbox! Each episode, one lucky individual gets exactly 1 minute to present their rant-of-choice to the world. Any topic is on the table – clinical, academic, economic, or whatever else may interest an EM-centric audience. We carefully remix your audio to add an extra splash of drama and excitement. Even more exciting, participants get to challenge 3 of their peers to stand on a soapbox of their own! 

Dr. Marc Probst
Associate Professor, Emergency Medicine
Mount Sinai School of Medicine, NY

#FutureSoapboxChallenge

References

  1. Probst MA, Kanzaria HK, Shoenfeld EM, Menchine MD, Breslin M, Walsh C, Melnick ER, Hess EP. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Ann Emerg Med. 2017 [In Press].

Dr. Andrew King
@akingermd
Associate Program Director & Medical Education Fellowship Director
Wexner Medical Center, The Ohio State University, OH

#FutureSoapboxChallenge

Dr. Venkatesh ‘Venk’ Bellamkonda
@VenkBellamkonda
Emergency Medicine Physician
The Mayo Clinic, MN

#FutureSoapboxChallenge

 

Author information

Sam Shaikh, DO

Sam Shaikh, DO

Editor, 60-Second Soapbox series
Assistant Clinical Professor, Rocky Vista University
Clinical Instructor, University of Colorado School of Medicine
2014-15 ALiEM-CORD Social Media and Digital Scholarship Fellow

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