When I was interviewing for residency, I was repeatedly asked what I liked about emergency medicine.  I answered as best I could, but really how the hell was I supposed to know?  My sum experience at that point was one month of following a senior resident around, and my main job was to stay out of his way.

Now that I practice emergency medicine for a living, I know all too well what makes for a good shift vs. a bad one.  And a lot of it I could never have guessed.

So here is my top ten list of stuff that determines if I have a good or bad shift, in order of least to most important.   

10. My Pen — If I could only take one thing to work with me, it’d be a pen.  If I could bring two things, I’d add a stethoscope, and if I get three things I’d throw in a PDA.  Anyway, my point is a pen is absolutely essential to what I do.  I can’t order stuff, fill out discharge instructions, or write prescriptions without one.  If I forget a pen, I’m already off to a bad start, since it’s next to impossible to find one at work.  I need a pen that works by clicking since I don’t want to be messing with a cap all shift.  It’s got to be thin or it won’t fit in my scrub pocket.  And sometimes I end up with a pen that won’t start working until I scribble with it for a few seconds or keeps drying up mid-word, which makes me want to go crazy.  And who needs that.

9. Which Shift Is It — The best shift is the one before a day off.  No matter how bad it gets, at least I know I don’t have to come back tomorrow.  The toughest shift is the first one back after a few days off.  I’m rested, but before I go in I usually start thinking “crap, how did 3 days off go by so quick?  I should have enjoyed them more.”  Then I get to work and the craziness gets to me more than usual because it’s in such stark contrast to the relative calm of not working as I continue to mourn the passing of my recent mini-vacation. 

If I work four shifts in a row, days 2 and 3 fall inbetween not just on the calendar but also in terms of how painful they are: I get more and more beaten down and quick tempered the more consecutive shifts I work, but at the same time I often start to find a rhythm or groove where things seem to flow more smoothly, and of course each shift that goes by is that much closer to the next run of days off. 

8. Expectations — If I’m coming in on a Sunday day shift for a slow doc then I just expect it to be hopping as soon as I get there.  If it’s relatively calm it’s a fantastically unexpected bonus.  Conversely, if I’m coming in to a Wednesday overnight for a fast doc, I expect the place to be pretty much in order, and if the department is crazy and full and there are 15 waiting to be seen and 3 ambulances on the way, then I feel the pain even more than usual.

7. Computers — Just before I started at my job, they switched from greaseboard and paper orders/charting to a computer based system.  When I first started I didn’t hear anything positive about it, I suppose because it was new and different and a lot of the docs and nurses are not particularly computer savvy.  I liked it, though, since I never knew anything else, we had something similar in residency, and I’m young enough to have used computers since junior high and just inherently feel comfortable with them.

All that being said, nothing pulls the trigger on my temper faster than when the freaking computers start acting up.  I can have a patient yelling and cursing at me and more than anything I feel a bemused detachment, but boy have the computer freeze up for ten seconds or so and I’m slamming the mouse down and letting my own string of cuss words fly.  And when the system actually crashes, and we have to go back to a greaseboard, and downtime forms, and paper medical records, and labs delivered by fax, it takes all the will power I have to fight the good fight and continue to press on.

6. How Busy Is It — When it’s super busy it’s stressful.  Patients get upset, staff is stressed, and I run myself ragged while worrying about the quality of the care I’m delivering.  A really slow night is better but not ideal — even though by default I’m lazy and hope everytime I come to work that it’s slow, the reality is a slow shift is a long shift, I resent the patients that do come for making me work, and I get paid per patient seen so there’s really no point to my being at work if I’m not busy.  The ideal shift is a steady stream of patients to where I’m constantly working but not rushed, that tapers off near the end of my shift so I can get out on time. 

5. Patient Types – Good patients have a legitimate problem, are able to succiently describe it, are nice, intelligent, appreciative, and reasonable.  Bad patients, well they’re easier to describe.  They come in for inappropriate reasons, whether it’s to use the ER as a primary care facility, for clear non-emergencies, or for secondary gain like trying to get out of work or score some vicoden.  You don’t need to go to the ER if you have a cold.  Or two months of belly pain.  Or you wet the bed or want a pregnancy test or any of the other absurd things we see as ER docs on a daily basis.  Bad patients have trouble describing what their problem is.  They are slow and ramble and get off subject.  They don’t know their medical history or meds and get irritated when I ask.  They have vague complaints which in all likelihood represent nothing but occasionally turn out to be something real.  Bad patients are self-absorbed and don’t understand that other patients in the ER need attention too.  If I see 20 good patients I feel like my job is easy.  If I see 20 bad patients I start wondering why I didn’t become an orthodontist.   

4. Staffing — Sometimes the nurses on are hard-working, self-directed, and have my back.  Sometimes they’re new, or worse stupid, or even worse lazy.  Some nurses tend to call in sick, leaving everyone else to pick up their slack.  Some of the on-call docs are pleasant, trust me, and have the patient’s best interests in mind.  Others are jerks, will fight admissions because of stupidness or laziness, and I know a few that will make medical decisions based on the patient’s ability to pay.

3. Competency — It’s amazing how different I can feel about myself as a doctor after a shift.  Some days every diagnosis is straightforward, every dispo is clear, every procedure goes smoothly, every call I make to an admitting doc sounds intelligent.  If I have bad news to give I find the right words and tone and mood.  The nurses like the job I’m doing and the patients seem to like me and even better respect me.  I’ll leave the department feeling like I’ve arrived professionally.

And then invariably I’m brought back to earth with the opposite of everything above.

2. Patient Complaints — Some days I’ll just slog through patient after patient, trying to convince parents that their kid doesn’t need antibiotics, dealing with belligerent drunks, half-baked suicide attempts, drug seekers, and sending home a lot of folks with vauge complaints that sure seem (and I sure hope) to be psychosomatic, or at least benign, in nature.  I’ll finish a shift like this and feel like all I did was push paperwork and try to convince people who feel otherwise that really there’s nothing seriously wrong.  It’s not very satisfying.

But within the muck are some really interesting cases that make emergency medicine fun.  I’ve put shoulders, ankles, elbows, and yes jaws back in place.  Made ugly cuts look pretty.  Shocked wayward hearts back into rhythm.  I’ve found temporal arteritis when the primary doc couldn’t figure out what was wrong.  I did a spinal tap on an afebrile baby that didn’t look quite right and found early meningococcus.  I found a giant PE in a pregnant patient.  I don’t mean any of this in a bragging way – believe me no one knows my limitations as a physician better than myself – but rather examples that remind me that as much as I work to live as opposed to the other way around, there are some really amazing moments on the job.

1. Efficiency — The above moments are great, but few and far between.  On a daily basis, nothing brings me more satisfaction then feeling like I am working efficiently.  The other day I saw 28 patients in 8 hours, did a couple of procedures, kept people moving, and left within 15 minutes of my shift ending.  It was fantastic.  I had to have a lot of things go right for me to have a day like that, like having the nurses, techs, lab folks, and radiology techs working as hard as I was, and having a lot of ”good patients” with fairly clear cut problems.  Alternatively, when I feel like I can’t get moving, because of issues with staff, difficult patients, or bad workups on my part, I get really frustrated. 

I find it odd that of all things feeling super-efficient is what brings me the most satisfaction on the job.  I’d pontificate on this further but this post has ended up being so insanely long that I doubt anyone made it this far with the possible exception of my mom.