Living like a resident means working a 80 hours per week, snagging free food, and driving an old beater car.

When doctors graduate and become attending level status, we want to spend our hard-earned money.  For the most of us, this is a big mistake.  Why?

First off, we have an ocean of student loans to pay off.

Second, we have little to no savings during our time as students and resident.

Third, we will get used to a "rich" lifestyle and will be stuck on the never-ending treadmill of having more.

So, what's the solution?  Continue to live like a resident until you have all loans payed off, maxed out on your savings, have a 6 month emergency cash reserve, and work as much as you healthily handle.

"Medicine keeps getting harder. And fewer and fewer folks are doing it. America has no idea that the weight of it all is falling on the shoulders of the emergency physicians and hospitalists who lurk inside the trauma rooms and inpatient floors, the fast tracks and ICUs of their community and university hospitals. The pasty-pale, coffee-sucking, junk-food-eating Spartans of health care who will bear the full assault of health care reform when there aren't enough primary care doctors to manage an AARP convention, much less all of America."

Edwin Leap, Emergency Medicine News, January 2013

WE ARE SPARTA!!!

So, how can you get inspired?

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.

So I was reading Dr. Graham Walker's article, Operation Burnout. It made me ponder, why do nearly 80% of emergency physicians feel burnt out?  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. Haven't you noticed that when people are negative 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 enter the new position, you are super excited.

2. Stagnation - Things begin to get boring and everything becomes routine.

3. Frustration - The frustration builds and builds at work.

4. Apathy - It feels like nothing can change and you think you can't do any thing about it. 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 can become inspired.

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

1. Join AAEM, EMRA, and ACEP. Usually free or very inexpensive.

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 EM clerkship.

4. If you are really committed to one program, do an away rotation there. Although its not mandatory.

5. Check out www.freeemergencytalks.net and listen to these 3 lectures to start:
http://freeemergencytalks.net/2012/10/joe-lex-an-old-fogey-speaks-45-years-on-the-front-lines/
http://freeemergencytalks.net/2010/03/amal-mattu-finding-your-niche-in-em/
http://freeemergencytalks.net/2010/04/peter-rosen-beginnings-of-emergency-medicine/

6. Go to ACEP leadership & advocacy conference in May 2013. http://www.acep.org/LACHome.aspx?MeetingId=LAC

7. Score well on Step 1.

8. Get a really strong letter of reference, from at least one EP.

9.  Identify a niche in EM (US, EMS, Peds)

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

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

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 know 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 had better start running.




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

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 far more likely to become disable 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.

"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?

1.  Tintinalli's Emergency Medicine Manual - A quick reference to have in the ED during a shift.



2. Rosen's Emergency Medicine - Excellent book for residency training and volume of knowledge.

  

3.   Emergency Medicine Oral Board Review - Great study guide for the EM oral boards! Lots of practice exams.

  

4.  Manual of Emergency and Critical Care Ultrasound - My go-to book for bedside emergency U/S



5.  Clinical Emergency Medicine Casebook - Love this case-based emergency study guide!  Lots of pictures.



6. Emergency Medicine Decision Making - Learn how to THINK like an emergency physician.



7.  5 minute EM Consult - Super easy and handy alphabetized reference.  Yes, I did write a chapter:)

  

8.  12 Lead ECG - Amazing EKG book!  Three levels of knowledge.


9.   Rapid Interpretation of EKGs - Great for beginners!



10.  ECGs for the Emergency Physician - Binders of ECGs by Dr. Mattu!

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....

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: www.drraulruiz.com 

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: www.drraulruiz.com 

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: http://www.efsumb.org/ecb/ecb-01.asp

2) Ultrasound: A Practical Approach by William Marks.  http://www.amazon.com/Ultrasound-Practical-Approach-William-Marks/d...

3) Training in Diagnostic Ultrasound Essentials, Principles and
Standards, WHO Study Group report.  http://apps.who.int/bookorders/anglais/detart1.jsp?codlan=1&cod...

4) Manual of Diagnostic Ultrasound in Infectious Tropical Disease
(covers abdomen only, available by amazon too)  http://www.wfumb.org/publications/books.aspx

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)  www.pih.org/publications/c/manual


COURSES:
1)  Short Course on Abdominal Ultrasound in Tropical Disease  
http://www.tropicalultrasound.org/
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  
http://www.georgiahealth.edu/ems/COM/InternationalMed/Peru.html
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)

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: http://www.efsumb.org/ecb/ecb-01.asp

2) Ultrasound: A Practical Approach by William Marks.  http://www.amazon.com/Ultrasound-Practical-Approach-William-Marks/d...

3) Training in Diagnostic Ultrasound Essentials, Principles and
Standards, WHO Study Group report.  http://apps.who.int/bookorders/anglais/detart1.jsp?codlan=1&cod...

4) Manual of Diagnostic Ultrasound in Infectious Tropical Disease
(covers abdomen only, available by amazon too)  http://www.wfumb.org/publications/books.aspx

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)  www.pih.org/publications/c/manual


COURSES:
1)  Short Course on Abdominal Ultrasound in Tropical Disease  
http://www.tropicalultrasound.org/
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  
http://www.georgiahealth.edu/ems/COM/InternationalMed/Peru.html
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)

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)
http://itunes.apple.com/nz/podcast/emergency-medicine-tutorials/id441003312

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

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)
http://itunes.apple.com/nz/podcast/emergency-medicine-tutorials/id441003312

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

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.

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.

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)

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)

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!

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!