The most important factor determining your success/enjoyment of a rotation is your clinical preceptor. My advice is that, before you choose your sites for clinical year, you speak to members of the class ahead of you and ask who their favorite preceptors are. That is how I wound up at the Lebanon VA Emergency Department with Dr. Woodson.
While this was technically my “Ambulatory Care” rotation, I was in the emergency department. It was undoubtedly one of the best rotation sites of clinical year, and that was largely due to the efforts of Dr. Woodson. What made him unique as a preceptor was not just his interest in teaching, but the lengths that he went to to help me grow as a clinician. He spent an hour every morning (even on his days off) reviewing a topic with me, such as asthma or acute coronary events.
When we worked together, I was always in the driver’s seat. I have never had another preceptor who was patient enough to watch me manually enter every order, perform every physical exam, and do every procedure. Whenever he saw an order that he didn’t agree with, he would ask me to defend myself. If I made a convincing argument, the order would be kept. If not, then he would (via the Socratic method) ask me questions until I arrived at the appropriate conclusion. The experience was both challenging and empowering.
Thanks to his efforts, I walked away from this rotation feeling, for the first time, as though I could actually do the job of being a Physician Assistant. I gained more confidence and clinical competence from this rotation than from any other to date (and I am about to graduate).
Also I want to say that working at the VA was a particularly enlightening experience, as I got to see many of the downstream effects of war, including PTSD, drug/alcohol abuse, deafness, and of course physical disability. To be honest, I had not known much about “Agent Orange” until I started this rotation. One thing has become very clear to me: that we owe our men and women in service a heck of a lot of gratitude. More than gratitude, we owe them excellent care for their sacrifices.
- Be Proactive. There are many experiences to be had in the emergency department. You will get more chances to do procedures on this rotation than any other. The best advice I can give you is to not be shy. Ask for opportunities to gain experience. If a patient has an abscess, ask if you can drain it (even if the patient is not your own). If a patient is going to be intubated, ask if you can do the intubation. If a patient is coding, ask if you can do CPR. Depending on the specialty you go into, you may not ever get to do some of these tasks again. Don’t miss your chance! Even if you don’t go into emergency medicine, comfort with procedures is critical. At the very least, learn what it feels like to do effective CPR (just in case somebody drops in front of you). You will be a better provider for it.
- Don’t cut corners. This is basic (and important) advice for anyone in medicine, but can be life-saving in the emergency department. At the very least, you should be doing a heart & lung exam on every patient (even if they are there for a hang-nail). Most patients should get a basic abdominal exam, too. Not only is it good for documentation, but it also might just save a life. The bottom line is that patients don’t always read the textbook when they are ill. In other words, somebody complaining of persistent hiccups might be having a full-blown heart attack. I have personally had experiences where the doctor I was working with cut corners and missed major exam findings that I picked up on. A few of my classmates have had similar experiences. Don’t let time constraints affect the quality of your examinations. Even when you have been working for 20 years, the basics are just as important!
- Maintain hypervigilance. Remember that the most worrisome patients are often the ones who downplay their symptoms (those tough little-old-men who minimize everything). Sometimes being a patient advocate requires you to convince your patients to advocate for themselves. Don’t miss a pulmonary embolism because your patient thinks that their syncopal episode was “no big deal”. Remember that your elderly patients are often afraid of dying; as a result, they may easily be led into denial. Your job is not to comfort them by agreeing that they are “probably fine”. Your job is to point out the red flags.
- Don’t be afraid to redirect chatty patients. This is something that I struggle with. Almost every day, you will encounter patients who want to give you their life’s story. In most settings, you can get away with being nice and listening for a while before returning to their medical care. In the emergency department, however, you often do not have the luxury of time. I am often too nice and let patients ramble to no end. However, throughout clinical year I have picked up on soft ways of redirecting the patient and staying on task. But when soft doesn’t work, I have learned to appreciate being blunt. A few times I have said something to the effect of, “While I would love to hear more about this, I do have other patients to see. Can you tell me more about why you’re here today.” In my experience, patients are understanding and not at all offended. Also, being blunt once makes it much easier to redirect them the next time they get off track. It is not wrong to give a sense of urgency to your time. You are telling the truth. You do have other patients who need your attention. In the end, everyone is happier.
- Be a team player. There is a downstream effect to the way that you treat the nursing staff in the ED (and any other department). One time I was interviewing an elderly patient when they had an “accident” and defecated in the bed. I had to do a rectal exam and hemoccult on this patient anyway, so I told the nurse that I would stay to help her clean the patient. As a former ED Tech, this was a task that I was used to doing anyway. However, there was a genuine look of surprise on the nurse’s face because the docs generally walk out and leave the nursing staff to fend for themselves. For the rest of the rotation, this nurse gave me greater respect as a student and seemed eager to return the favor. She also sung my praises to the rest of the department. Of course, you don’t always have time to make these gestures, but doing so pays large dividends.