The Boards for Life Just how ready are you? Edwin Leap, MD, FACEP

The Boards for Life

• You have to look at my family first

• Its kind of the price of admission.

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• Now, why should you care what I think?

• Good Question, but then, Im standing up here and you arent.

• Actually, Ill tell you.

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• Ive been at this, in the same group, for 16 years.

• I have had the same wife for 19 years.

• I have experienced a lot.

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• Ive seen thousands upon thousands of patients.

• I have been yelled at by doctors.

• I have wanted to quit.

• I have been angry over and over.

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• I have driven my wife crazy.

• I have been sued.

• I have had to learn how to bill to make a living.

• I have learned how to get along with partners.

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• I have also learned how to feel compassion.

• People have moved me to tears.

• I have no regrets about my career.

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• I write a column that lots of our colleagues read.

• More importantly, I hear back from them about their struggles.

• They teach me a lot about the world of EM.

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• So, I know some of the struggles other docs face.

• I know the struggles my partners and I have faced. (And faced, and faced!)

• I know what my family has had to deal with.

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• I realized one day that all of this experience would make a good board exam.

• I mean, after your first board exam experience, how many practitioners can still write out the metabolic pathways in most poisonings?

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• Ive compiled a series of questions about the practice of medicine.

• Few people ask you these things.

• They are seldom covered on in-service exams.

• Here goes

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• The doctor who wins has

• A) the most wives (or husbands)

• B) the most money

• C) the largest debt

• D) the best patient satisfaction scores

• E) None of the above

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• Answer

• E) None of the above. There is no prize for most wives, largest debt, happiest patients, most alcohol consumed or even most money earned.

• There is no prize! There is only your life.

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• Once youre a rich doctor, you will romance your partner with:

• A) Trips to Tahiti

• B) Trips to San Francisco

• C) Trips to Chicago

• D) Trips to the grocery store

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• D. Welcome to being low on the totem pole again! You get weekends, nights and holidays.

• But, fun and romance can be just as good in the middle of the week at home as they can on a weekend far away.

• Embrace your place.

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• True or False:

• Your spouses friends will drop their pants and ask youre married to a doctor, whats this rash?

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• TRUE!

• Spousesdont feel bad. Intercourse transmits lots of things, but not a medical education. The answer to the rash question is always syphilis!

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• True or False:

• When your spouse asks you to do something around the house after work, you can say, Give me a break, I worked all day taking care of sick and dying people!

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• True. You can say anything, since this is America. But youll regret that one for a long time.

• Tip: Comfort Inn is usually a nice place to stay, and has breakfast.

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• Look, youre a doctor at work. At home, youre a person who has to take out the trash like everyone else.

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• Youre in a nice restaurant with your wife, when a beautiful, buxom waitress says, with a smile and wink, Hey Doc! You should say:

• A) Her name is Chastitee. Isnt that cute?

• B) That reminds me, do you like leopard print?

• C) She has the hottest tattoo on her

• D) Explain that shes a transgender patient.

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• D is a reasonable attempt, but there isnt a good answer. People will flirt, just dont flirt back. Remember to pay attention to your spouse and dont be flattered by patients, who are mostly crazy as bed-bugs, however cute they may be.

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• Additional Caveat:

• Your spouse doesnt want to know how many people you see naked on a daily basis, even if you explain that theyre mostly disturbing.

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• While Im on this point:

• True or false: Its OK to have an opposite sex best-friend at work?

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• Well, if your spouse were here, what would she or he say?

• Lets do a little survey.

• True or False?

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• FALSE!

• Listen, you can have friends at the hospital, but no one should be your intimate confidant besides your spouse.

• Otherwise youll be confiding in an attorney.

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• There will be NO sex at home until:

• A) The bills are paid.

• B) The dishes are put away.

• C) The kids are asleep.

• D) The bathroom is clean.

• E) It depends

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• E. It depends on the couple. The point is, romance and real life are tied together. Pay attention to the minor details of your world, that is, if you want to keep having sex.

• More to the point, pay attention to the details of the lives of your loved ones. Put them first.

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• Now that youre a doctor you are:

• A) a highly trained medical professional

• B) a life-saving member of the emergency response system

• C) a heroic figure to nurses and patients

• D) a factory worker

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• D! You are a factory worker!

• Your job is to keep the bodies moving through, and to do it as quickly, safely and efficiently as possible, so that no one has to wait so long that you give them movie tickets.

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• Of course, youre actually all of the other things too.

• Just keep it in perspective.

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• The customer service model will always guarantee good, cost-effective care for your patients. True or False.

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• False. We should try to please our patients to the extent that theyre customers. Many of them are not. Customers pay when they leave the store.

• Its OK that some of our patients dont pay. But that makes them patients. We care for them because were dedicated.

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• And by the way, our medical ancestors didnt wade into Cholera epidemics, the Black Death or battlefields because the customers were dying everywhere.

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• They did it because it was right and because they had a commitment to easing human suffering.

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• When you die:

• A) The house of medicine will collapse.

• B) Patients and staff will wail in sack-cloth and ashes.

• C) Theyll name a procedure or drug in your honor.

• D) People will walk over your still warm body and keep working.

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• D. People will walk over your dead body, take all of your vacant day-shifts and sift through your pockets for change.

• You are disposable, so dont let this medical thing be your whole world. Again, its all about perspective.

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• Its 3 am on your fourth night shift.

• Bubbas back pain has returned. Do you:

• A) Schedule an MRI

• B) Do a textbook neuro exam

• C) Write for 15 of his favorites and say bye bye

• D) Give him a sound lecture on drug use

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• C! Remember, when fatigued, sometimes its OK take the path of least resistance. And remember, always, that The big possums rule the night. You arent one of them, so dont try to make sense of them.

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• No, no, no, dont give everyone drugs.

• And always be thorough or youll regret it.

• Even annoying people need MRIs sometimes.

• Even possums get terrible diseases.

• But dont feel guilty when youre too tired to fight anymore, thats all Im saying.

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• If you suddenly cant be a doctor, because youre miserable or ill:

• A) your life isnt worth living

• B) youll remain the same person

• C) your wife will run off with the broker

• D) your children will mock you

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• B. Youll still be the same person. See, medicine doesnt define you. Its a job. Remember that! Its a job. You are a person. And your family loves you, not your degree or title. You are not wholly defined by your career.

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• IF you decide to let your career validate and define you, you will be:

• A) chairman of the department

• B) residency director

• C) ultimately a miserable individual

• D) Winner of the Nobel Prize for Medicine

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• C. Youll be the sort of miserable doctor that says to me how is that my problem?

• Or that answers out of town pages by calling collect. (True Story).

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• True or False:

• The Golden Rule also applies to your partners.

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• True. As much as you can, create a family in your group. Help each other, support each other, stand by each other. Be fiercely protective of each other.

• Dont be snarky.

• In the end, it will all pay off.

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• Now that youre out of residency:

• A) You need a Lexus convertible.

• B) You need a beach house.

• C) You need a home by a golf course.

• D) You need some common sense.

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• D. You need to be smart. Dont spend money like a doctor; spend it like a factory worker (which weve established you already are).

• People will only be able to push you around to the extent that you need a lot of money.

• Dont be a slave to money!

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• Doctors get miserable when they have to do too much of what they dont love in order to make ends meet.

• And when they believe that doctoring is everything to them.

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• If youre free of both traps, youll be a rare commodityhappy at work and at home.

• Youll drive other doctors crazy, too!

• And youre patients will love it.

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• If you are sued you should:

• A) Immediately leave medicine since youre a failure

• B) Start drinking heavily and fall into a spiral of bitterness

• C) Recognize that youre just part of the food chain and move on

• D) Double or triple your CME participation

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• C. You will probably be sued. And it may not be for an obvious error. (Though it will be obvious to everyone who reviews the case after the diagnosis is known)

• A lawsuit does not reflect on your person, skills, or worth. Youll have helped and saved exponentially more than patients than will ever sue you.

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• Over your career, you will have helped and saved exponentially more than patients than will ever sue you.

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• And remember this:

• Everyone, everyone, everyone dies.

• Even if you get a clean kill, they were not going to escape the reaper.

• Not an excuse, just more perspective.

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• Be careful, be compassionate, pay attention and stay up to date.

• Remember, though, that youre part of the economic food-chain.

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• What your wife and children want most is

• A) your time

• B) a vacation in Australia

• C) a ski boat

• D) a home theater

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• Well, they might want all of that, but what they want most is your time, lavished on them without reservation.

• Time is the most precious thing you have.

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• In Emergency Medicine you have the unique opportunity to arrange a schedule that truly fits the needs and desires of your family.

• Take advantage of this rare gift.

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• Your spouse wants to explore a new career or interest that will require your time.

• A) Tell him to wait until you both retire.

• B) Tell him youre a doctor and he doesnt need to do anything else except help your career.

• C) Laugh and tell her to get you a beer.

• D) Help her in any way possible.

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• C is the quick ticket to a head injury.

• D is the answer.

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• Remember always to help everyone fulfill their dreams if its in your power; especially those you love most.

• You got what you wanted so far, didnt you?

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• The best way to get your point across as a doctor is to:

• A) Be calm and in control

• B) scream

• C) use a lot of @#$% profanity when you &*$*& talk to those &^$#@doctors and patients!

• D) Throw things

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• A. Nothing unnerves other doctors and patients like calm confidence. Always control your emotions. Act, dont react. And remember, dont be an jack$#%.

• Doctors who scream and curse are acting like children. Dont be one.

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• When people do annoy you:

• A) Be passive aggressive.

• B) Cower before them.

• C) Plot revenge.

• D) Remember your power!

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• Well, sometimes passive aggressive makes you feel better. So, whats your emergency?

• Generally, just plow through and dont let them control you.

• For difficult doctors, remember Chisholms rule:

• You can always hurt them more than they can hurt you!

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• Further consultant taming advice:

• Dont back down, look them in the eye, be firm, be prepared with data, be educated, leave emotion out of the discussion as much as possible.

• Dont offer to take them outsidelike I did.

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• When youre finally alone and in charge in an emergency department:

• A) Youll feel powerful.

• B) Youll feel stupid.

• C) Youll feel terrified.

• D) All of the above.

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• The answer is D!

• Its terrifying and wonderful. Being scared means youre intelligent. Being confident means youre well trained. Thinking youre stupid is just accurate.

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• The stupid feeling goes away after 20 or 30,000 patients. But its normal to feel unprepared; you arent. Youre just honest. Which brings us to the next question

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• Patients will usually present with textbook signs and symptoms: True or False?

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• False! Textbooks are good and useful. But patients dont read them.

• Patients have a surprising way of making you wonder what you were doing during medical school.

• Other than treating your hangover

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• For example:

• A ruptured appendix is usually preceded by:

• A) Fever, nausea and migrating RLQ pain

• B) A funny feeling of tingling all over

• C) A spider bite

• D) A sound like a shotgun goin off!

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• D, though C is a close second. The combination of tingling all over and a sound like a shotgun has a very high positive predictive value for a ruptured appendix.

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• Most Myocardial Infarctions present with:

• A) Crushing substernal chest pain

• B) Pain radiating to the neck and shoulder

• C) Nausea and diaphoresis

• D) A funny tinglin all over

• E) All of the above, emphasis on tingling

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• E. But watch out for the prevalence of tingling in any and all disorders. It is very powerful magic among your patients.

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• Toxicology means:

• A) Cool envenomations

• B) Fascinating nomograms

• C) Interesting pharmacology

• D) Pathetic rednecks taking Xanax

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• The answer is D. Doesnt anyone keep Cobras anymore?

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• Ejection from a vehicle requires:

• A) Whole body CT scanning

• B) ATLS protocol

• C) Rapid sequence intubation

• D) Security to keep the drunk patient from smoking in the parking lot

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• The answer, again, is D.

• I was never so surprised as when I realized that patients just dont die when they should, and frequently do when they shouldnt.

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• The point is this:

• Things dont always look like they should.

• You arent stupid or unprepared.

• Real life medicine is just weird.

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• Patients who appear to be wing-nuts:

• A) Usually imagine their illnesses.

• B) Invent silly symptoms to drive you bonkers.

• C) Actually get sick with bad things.

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• C. They get sick too!

• Dont get burned by assumptions.

• Dont practice what I call wishful medicine. I dont want it to be a stroke, so it cant be!

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• Back to other stuff:

• Your worst enemies, as physicians, are:

• A) Your patients

• B) Administrators

• C) Yourselves

• D) Lawyers

• E) Insurers

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• C. Yourselves. No one has power over you that you dont give them, and no one can make you unhappy except yourself.

• And all of them, like you, are just trying to get through the day, go home to watch American Idol and frantically clean the bathroom.

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• As an emergency physician you can:

• A) Live where you want.

• B) Work as much or as little as you want.

• C) Make as much money as you want.

• D) Only have two of the above.

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• This is Olingers Rule, named for one of my instructors. The answer is D. You can, generally, only have two. Choose wisely, young Jedi!

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• Which of the following are signs life is not going well:

• A) You wish you could be a fighter pilot.

• B) Your wife just got implants and colored her hair.

• C) You feel that everyone is out to get you.

• D) Your children never let you sleep.

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• Well, everyone wants to be a fighter pilot.

• Everyone IS out to get you.

• Your children dont let you sleep because they like you.

• If your wife changes her breasts and hair simultaneously, you need to be home more. The answer is B. Doubly true if your husband gets implants and changes his hair.

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• A few closing points:

• You will be fine. You are motivated and capable. You will touch lives in ways you never even imagined, and ways you will never know about.

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• If your heart calls you to some other path, thats OK too. You may practice medicine until you die, or until next year. Either way, its fine.

• Be true to your calling, whatever it is.

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• Love the people entrusted to you. Love them with total, fearless, reckless love, and lavish them with your time.

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• If you want to be a great physician and human, listen to old Philo of Alexandria:

• Be kind, for everyone you meet is fighting a great battle.

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• Final Question:

• Yes or no: Has it been worth all of the years and effort youve put into it?

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• Answer:

• Its up to you to decide, and to live accordingly.

• Congratulations!