Originally published for the Elsevier Australia Medical Student’s Blog July 2015
This concludes my 10 week stint as an ED intern, a period which was the most valuable educational experience I have had since commencing medical school. The experience at the front line is unique, and this blog entry reflects my personal experiences only. It is not meant to be a blueprint of how ED’s function and the role of the intern within them.
Your experience will probably be vastly different! Please share your thoughts in the comments below, or tweet me @lukmananderson
1. You have to use your brain!
This is medicine in a purest form – the undifferentiated patient. Each patient a blank slate, waiting for you to etch your impressions and differentials, tainted only by the snippet of information you receive from triage.
It is a period to apply clinical skills in their full form, all the way from history, to diagnosis, management and referral. This is a huge responsibility, but is also hugely rewarding.
It is a true test of your skills as a generalist. I recall one shift having to make referrals to psychiatry, O+G, general surgery and ENT. There’s also plenty of ophthal to be enjoyed, and it’s a good time to pick up some skills on the slit lamp.
This period has made me acutely aware of my own cognitive biases when assessing patients. The availability heuristic struck when a pregnant lady I was caring for ended up having appendicitis after some borderline exam findings. My rate of ordering ultrasounds skyrocketed after that.
This is because I am a jackass – all doctors are jackasses – and you will be less of a jackass if you listen to this talk by Chris Nickson of the SMACC team and evaluate your own biases. Better yet, pick up Thinking, Fast and Slow by Daniel Kahneman for the definitive text on cognitive bias.
2. The definition of ‘emergency’ is a flexible one
Most of my patients have been triage 4 or 5 – semi-urgent or non-urgent. It is easy to start to think things like, ‘why couldn’t this wait til morning?’ or ‘that’s not an emergency.’
The only thing that matters is that the patient believes they have an emergency. Often it’s a matter of listening to their story, ruling of out red flags, providing reassurance, and sound discharge advice.
I have learnt to ask about their motivations for coming to the ED, what their specific worries and concerns are. Addressing these defuse most emergencies.
3. It’s a team game
No man is an island in the ED, especially the ED intern. Each case is discussed with a more senior medical officer, and a management plan is developed together. Communication is key to the smooth running of a department, and regular handover meetings ensure that everyone is aware of their role and responsibilities.
The presentation of cases at handover is an art. A balance needs to be struck between brevity and relaying all of the key information. You soon find out that emergency physicians are mostly allergic to long case style presentations.
4. GPs make the world go around
‘Please make an appointment to see your GP next week’
‘If you notice these symptoms, please follow it up with your GP who may organise further investigations’
‘This pain is best managed in the long term by your GP’
There are so many medical issues that simply cannot be managed in a one-off ED visit. The continuity of care simply does not exist.
5. You can take your time
As the intern, the main expectation is safety. Time pressures are less of a priority. This means you can be thorough, and have an opportunity to really touch on key aspects of patient communication that might slip away from a more senior clinican.
A recent survey from the Bureau of Health Information, for example, revealed that one in five patients were not told what signs and symptoms to watch for on discharge, and one in four were not told about the side effects of new medications (1).
You have the chance to address these various issues and concerns, and play a key role in ensuring good outcomes for the patients you see.