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I’m 3 years out of residency and while I thought I was a great resident, I find that I’m only an average attending. What happened and how can I take the next step to have the respect of my ED and hospital colleagues as a great physician?
Signed,
Trying to Improve

Dear Trying to Improve,
I recently was in California wine country and was introduced to someone who has been called one of the best winemakers in the country. I was intrigued by what makes a great winemaker, particularly one who was under 40 years old. It turns out, as my grape growing friend advised me, that many of the same attributes that make a great winemaker can be found in a great physician—anal retentive behavior, an excellent knowledge base, a desire to learn new things and probably a little bit of luck. 
 
Your patient’s perspective
For the patients, being a great physician is not all about knowledge. In fact, I’ve seen incredibly loyal patients of docs that I consider quacks. A patient expects the physician to manage the case correctly and frankly rarely knows if their workup is inappropriate. It’s bedside manner, keeping the patient informed and allaying fears that carry the day in the patient-physician interaction.

Your colleague’s perspective:
If I’m working a busy shift, I’m looking for someone who can move the ED efficiently as well as voluntarily take some of the tough cases and the undesirables – the sickies and the homeless drunks, for instance. As a chairman, I think it’s my responsibility to take every such case, but I love it when my colleague is a step ahead of me, taking care of the crashing 6 month old or the homeless guy who is here for the 15th time this month. I’ve worked with other really good docs who seem to slow down when they’re working with someone slower than them. We all know who can move the meat so it’s important to bring your “A” game everyday. Be a team player. Bringing something of value to the team every day is critical to being a clinical leader. Finally, giving a good and tight sign-out or staying over your shift to help us older guys learn to use ultrasound is just icing on the cake.

Your boss’s perspective (the chairman & hospital administrators)
Core measures, efficiency, and achieving and exceeding the department goals and metrics are what keep this group smiling. Also, maintaining a minimal amount of complaints from patients, nurses, and the attending staff will make your chairman happy. A patient complaint or a missed pneumonia case takes me 20-40 minutes to review and officially respond to, including counseling the physician. The doc who doesn’t waste my time because they were in a rush and skipped a step or was rude is going to be my friend. Also, for the hospital administrator, getting patients into the right bed the first time, be it an ICU, observation or home, gets them the best financial bang for their buck.

The private practitioners’ and hospitalists’ perspectives
Sure, saving their butt when they want to send a patient home or making the diagnosis of Guillain Barr’e, tetanus, or transverse myelitis will enhance your reputation and get people talking about you, but don’t count on those events happening too frequently. More importantly, properly working up patients, making timely phone calls and making the private guys look good will endear you to them. I had a good doc call a private attending about a patient that needed admission to the ICU for sepsis but also told him he couldn’t find a source. After the attending arrived, undressed the patient, saw the deep sacral decubitus and then diagnosed osteomyelitis in the patient, you can imagine what he thought about the doc who called him. Yes, our EP made the diagnosis of sepsis and got the work up going. However, the great doc is anal retentive enough to undress every patient, do a thorough exam and not report misleading information.When all is said and done, who I want caring for my critically ill family member may not be whom I want to work my shift with. When I interview new job applicants, I’m always trying to hit the trifecta—speed/efficiency, Oslerian brilliance, and an Oprah-like bedside manner. While I’ve been fortunate enough to work with a few people like this through the years, most of us have a weaker area. Understand and address your weaknesses and emulate the work behaviors that you respect (the efficient docs in my group carry spectralink phones and the slower docs don’t—does that say something?). Be diligent and anal retentive and bring your “A” game to work every day and you will work your way towards being a great physician. A little luck in making the right zebra diagnosis or having a patient sing your praises in a letter to the hospital CEO doesn’t hurt either. As my friend the grape grower says, there aren’t great winemakers, just great grapes. Practice the art of medicine and take great care of your patients in all regards and your reputation will take care of itself.

Mike Silverman, MD is the chairman of emergency medicine at Harbor Hospital in Baltimore and is on the faculty at the TeamHealth Leadership Academy.
Dr. Silverman was recently named Affiliate Medical Director of the Year by TeamHealth East.
 

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