So, you have found yourself in an emergency department (ED). We are so happy you are here. Thank you for coming to lend us a hand – we won’t forget it.
We can imagine that this place feels different than the wards or the operating theatre or clinic. Some of that difference has to do with the types of patients we see, the decisions we make, and the care we provide but much of it has to do with something even more fundamental than that, ED culture. That culture is the culmination of the values, beliefs, and practices that make us who we are. As an anthropologist and emergency medicine resident, I am going to share with you a few key facets of emergency medicine culture that will facilitate your rapid transition to our side of the consult.
1. Emergency medicine is a team sport.
This is easy to say, but what does it actually mean?
It means we fundamentally believe that every single person on the team plays an integral role in providing care and keeping the machine going. How do we live that value? We learn people’s names, we say please and thank you, we seek input from nurses and paramedics, and we ask the unit clerk about his kids. Staff call us by our first names. We pitch in where we can (getting a patient water, changing linens, help porter patients etc.) and we try to do all these things with a smile. We check in on each other after tough cases, we are honest with our feedback, and we ask our colleagues how we can help. There is no room for ego. We live this value because we are humans, and it makes the workplace more fun, and because we rely on every individual on the team to be psychologically safe1 in critical moments when we must rely on them to speak up. We know that “teamwork makes the dreamwork”, especially in trying times.
Welcome to the team.
2. The charge nurse is the boss.
There’s not much more to say about this one. It is just the truth. Embrace it. They are the ones who are there for 12-hours a day, and their only goal is to maintain situational awareness with regards to the whole department and the rest of the hospital.
3. Perfect is the enemy of good.
This reality might make you feel uncomfortable. We have a strong duty to individual patients yet sometimes we are forced to come up with good, but not perfect plans for them. This will probably become even more relevant as the pandemic ramps up. Good questions to ask yourself include “does this seem safe?” or “would other doctors think this is reasonable given the circumstances?” or “will I sleep tonight with this choice?” If the answer to all of those questions is, “yes!” then your plan is probably a good one. It may not be perfect, but it is good.
Striving for absolute perfection in the emergency department, while admirable may impair your ability to do the most good for the most number of patients…and it will actually destroy your soul. This isn’t an excuse to cut corners, be lazy, or provide sub-standard care, rather it is a realization that we are making difficult decisions with limited information without the luxury of time. We usually do that very well, but we can’t always do it perfectly. That is okay.
4. We are good at being wrong.
Because we are good but not perfect (see #3 above) sometimes we are wrong. This job is humbling. The radiologist will report a fracture in the final x-ray report for that patient you sent home with an ankle sprain the night before. Internal medicine might identify a PE in that patient you referred with a COPD exacerbation. That STEMI that went to the cath lab was actually a dissection. Every time we hear about these cases our hearts sink a little bit. We think (and sometimes perseverate) about what we could have done differently, what we missed, what we should have seen, and how we can move closer on the spectrum towards perfect. After getting over the initial gut punch – usually through talking to colleagues (see #1 above) – we incorporate any lessons into our practice and then see the next patient. For more on this, check out our other related resource on the Emergency Medicine Mindset.
5. We love asking for help.
This one you probably already know. Emergency physicians excel at asking for help. In fact, it is something we are best at. You are usually on the receiving end of those phone calls. Now we are here for you, no matter what. There is no stupid question. Worried about a patient? Ask for help. Don’t know where something is? Ask for help. Don’t know what to do? Ask for help. Want an extra set of eyes on a rash? Ask for help. You can officially call yourself an emergency physician when you ask more questions on a shift than you answer.
I hope this gives you a glimpse of the values, beliefs, and practices that are common to most emergency departments in Canada. Of course, culture is local and there will be variations and differences to these themes. For more insight into the culture of emergency medicine check out these posts on the EMMindset on RebelEM2 and First10inEM.3 For a more in-depth look at specific values, beliefs, and culture of emergency medicine check out my anthropologic study on the topic here. We are grateful to have you on board.
You will be surrounded by all sorts of people that want you to succeed. Be like us, ask for help. Maybe you just need the password for the locked bathroom, or maybe you want someone to chat with about a bad case you’ve just had. We all support each other in the ED. You have been adopted to our family, and you are now part of our tribe. Welcome to the Emerg family.
Recommended reading, videos, and podcasts
- Justin Morgenstern. First 10:EM. The EM Mindset: Not Knowing
- Purdy et al. (2019) Identifying and Transmitting the Culture of Emergency Medicine Through Simulation (Canadian first author)
- REBEL EM: The EM Mindset (CAUTION: American resource)
- Nickisch & Edmondson (2019). Creating Psychological Safety in the Workplace. HBR Podcast.
The following is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.
This post was edited by Dr. Teresa Chan MD FRCPC MHPE DRCPSC. This post was copyedited and uploaded by Evan Formosa.
- 1.Edmondson A, Nickisch C. Creating Psychological Safety in the Workplace. HBR Ideacast. January 2019.
- 2.Rezaie S. The EM Mindset. REBELEM. https://rebelem.com/the-em-mindset/. Published July 12, 2017. Accessed April 6, 2020.
- 3.Morgenstern J. EM Mindset: Not Knowing. First10EM. https://first10em.com/em-mindset-not-knowing/. Published February 14, 2019. Accessed April 6, 2020.