You’re the Pilot: A Guide for Successful Shifts Your First Year Out of EM Residency

So, you’ve signed your first contract. You’ve successfully navigated your first real job search in nearly a decade. You’ll be graduating from residency in the near future, and it’s finally beginning to hit you: all too soon, you’ll be on your own.

As USACS’ Vice President of Marketing and Recruiting, I am often in touch with residents at this stage in their careers. Concrete advice for surviving – and succeeding – on your first shift can be in short supply.

So, it’s time to get down to brass tacks. Pedal to the metal, rubber hits the road. Pick your metaphor, but for this post it’s all about picturing your shift as if it’s a flight, and you’re the pilot. So, here we go:

The Pre-Flight Check-list

The pre-flight check-list is everything you do before your shift actually starts.

Have a ritual

For night shifts, I actually listen to Black Eyed Peas “I gotta feeling” as I drive to the hospital. You know the song: “I gotta feeling… that tonight’s gonna be a good night.” Whatever it is, do something before each shift that is going to put you in the right mindset. It’s easy to think about all the bad cases that you may encounter, but now is the time to prepare mentally and focus on the good. You are on your way to do what you’re trained for: care for patients.

Get there early

Show up 15 minutes early. When you arrive, say hi to everyone you can, especially the charge nurse. It’s a great chance to build rapport but also to get a feel for what’s happening that day. If there’s something causing an issue in the department or hospital, ask, “What can I do to help with that?”

Set up your logins, get your work area in order. If your shift starts at 3pm, that means you should be in a room seeing a patient at 3pm, not just turning on your computer.

The Take-off

At USACS, we have an Efficiency Academy where – don’t have a seizure now – we’ve learned that the fastest docs are able to initiate care for upwards of ten patients in their first hour. You won’t be expected to do that, so don’t worry. But understand that it can be done. So how do they do it? They use their team around them.

When your shift starts, priority #1 is always, who is sick? Sick trumps everything. If there is someone who needs your immediate attention, you must see them first. Priority #2 is, does someone need something done: a workup with chest pain, pain control and imaging for an injury, whatever. Go in and get started what needs to be done.

If there is a bolus of patients to be seen, I’ll utilize what I call a “pop in.” I’ll tell patients, “We’ve had a rush of patients, so I’m going to talk and examine you quickly so I can get your care started. But I will be back so you can tell me more and I can do a thorough exam.” They always appreciate it. Get those patients’ care plan quickly started, then start circling back.

Don’t let external factors control your shift

Look around the ED. What external factors are there right now that will make your shift difficult, if not miserable, if they’re not taken care of? If you’re a single provider, and there are patients boarding and you don’t actively manage around that, it’s going to be a tough night.

Managing the ED can be like a game of chess: look for issues, think ahead and figure out a strategy to win. You have to own the department and not let external factors control you. If there’s a chest pain who is simply waiting to go to observation, or multiple prolonged diagnostics such as MRIs, think creatively about how to create space and see those that are waiting. There usually is a more efficient solution if you seek it out.

Use your team

If your hospital allows, use the nursing staff to help you and your patients. Provide them standing PRN orders for pain and/or nausea and empower them to enter orders via protocols. Giving them appropriate autonomy will make your entire department far more efficient.

Avoid serial testing

Serial testing is when you order the first test, then it comes back and then you order another test. Then it results and you’re following it with another test. If you find yourself adding on tests like that, step back and honestly ask yourself if you could have and should have ordered them all up front. It’s not always avoidable, but many times it is.

Instead aim for parallel testing. If you were never going to disposition a patient without a certain test, you might as well get that test up front.

Cruising Altitude

Dispo down

As your shift reaches cruising altitude, our patient load is often near our max. If you start to feel overwhelmed, that’s when mistakes can happen, and you need to “dispo down.” This allows you to get your active list to a manageable level and reduce the turbulence in your mind.

Also, identify the inevitable “dispo blockers” up front. Do they need a urinalysis? Maybe a road test for an orthopedic injury? Whatever that dispo blocker is, talk to the patient and let them know: “This is the thing that’s going to keep you here. If you can help us complete that, we’ll get you home quicker.” Then talk to the nurse and get them on the same page. Now instead of just yourself, you have the entire team aligned.

Maximize time

In residency, patients are typically prioritized first by who is sick and then by who has been there the longest. But sometimes it works better to think about maximizing your up time. Can you bundle a couple of new patients that are geographically close? Can you update someone on test results while you’re up assessing someone else? Doing these steps in tandem can save you time by simply reducing the travel time back and forth through the ED footprint.

You should also be maximizing your down time. Research shows only two percent of people can actually focus on two tasks at once; everyone else is simply switching attention. Therefore, the rest of us really need to be efficient mono-taskers. An example is charting on a patient while your consult is being placed for that very patient. If their care is already loaded in your mind, you’ll be immediately ready to discuss them with your colleague when the phone rings.

Know your turnaround times

Know how long the lab takes to get things back to you. If you know troponin takes 60 minutes, don’t check for it at 30 minutes. It’s not gonna be there. Trust your process and know your lab will notify you or your team of any critical results. Constantly checking on tests is like being in an elevator and pushing the floor button over and over. It’s not going to get you there any faster.

The Landing

Cherry pick dispositions

It’s ok to cherry pick easy dispositions at the end of your shift. First and most importantly, it’s better for the patients. Two, it’s going to turn over the bed quicker, so it’s better for the entire department. Sore throats with a resulted rapid strep? Ankle sprains with a completed x-ray? See them and make that quick disposition.

Tee up for your partners

I have no problems with the physician in front of me cherry picking, and I also really appreciate them teeing up patients for me. You don’t need to do a full documentation, but if you can do a “pop in” and get the work-up started for your partners coming in, it helps everyone by speeding up the care the patients receive.

Get off the runway

We know from studying departments that physicians get less efficient after their shift ends. That’s why we really recommend people get off the runway. As soon as you can appropriately leave the ED floor, find an isolated area to complete your documentation and remaining tasks. You’re going to be more focused on getting it done and you’ll be out of the way for the next clinician coming in. Plus, you can avoid being the default EKG reader that happens to all sitting duck physicians.


You know those pilots who thank all the passengers on their way out of the plane? As an emergency medicine physician, it does a lot of good to thank the team you just worked with, as well as the next doc coming in to take over. Never forget that they are all your partners in doing something quite extraordinary: taking care of patients.