How Being a Scribe Will Prepare Me for a Career in Healthcare Administration

By CarolAnn Sudia CIM

As a recent college graduate, I’m often asked, “What do you do?” I reply with pride, “I’m a clinical information manager.” Ordinarily, I get one of two reactions: a simple nod, where clearly the person is pretending to know what that means, or they delve deeper and ask, “OK, but what is it that you do?” And though I’ve been working as a clinical information manager (CIM™) for a little more than six months, I haven’t quite perfected my elevator pitch yet.

What I Do

In short, I transcribe doctors’ notes; they tell me what’s happening with the patient, and I enter the information into the computer. But really there’s much more to it than that. I’m responsible for obtaining clarifications, which means I have to have the wherewithal to understand that in the world of medical documentation and billing, a simple diagnosis – say congestive heart failure – isn’t going to be sufficient; there are a multitude of questions that run rapidly through my brain to ensure accurate and thorough documentation.

It isn’t often that a doctor forgets to tell me one of the layers in a diagnosis, but if he or she does, I am responsible to ask. I am also responsible for freeing up the doctor’s time by calling in consults with other medical practitioners and for checking the progress of lab and radiology results so the next step in the patient’s care can occur as quickly and efficiently as possible.

The CIM Position  

The CIM position, also known as a scribe, is a multifaceted and complex position that doesn’t lend itself to a quick, three-sentence answer to the question “What do you do,” but it’s a rewarding position with a fast-paced learning environment. Even though my great Aunt Marge may never fully understand what it is that I actually do, I know that what I do makes a difference in the lives of the doctors I work with and the patients they treat – and that’s a pretty wonderful thing.

Medical School vs. Healthcare Administration

After I give the person who asked the follow-up question the lengthy speech on what it is I do, the next question is always, and without fail, “So you want to go to med school?” And to that question I can give a quick and definite answer: “No!” I can understand their confusion; I graduated top of my class with a science degree and now I work in a hospital, but the truth is, I never wanted to be a doctor, so no, medical school is not in my future.

I’m more interested in business and how I can apply what I’ve learned as a scribe to advance my career at Emergency Medical Associates or to move into hospital administration. Prior to being hired as a scribe, I had a rough time bridging the gap between science and business, but as a clinical information manager, I’m able to merge my love of science with my interest in building on my business skills in a position that allows me to constantly learn and grow.

What I’ve Learned

I’ve learned how to work quickly while maintaining the highest quality of work, and because to err is human, I’ve learned to how take criticism, grow from it, and make sure it doesn’t happen again. All of these skills will make me more marketable to any business job I apply for in the future; add to that my insider knowledge of which administrative operations frustrate and impede doctors more than help them, and I have an edge over most others applying for a hospital administration position.

Working as a scribe is an obvious choice for anyone who wants to go to medical school, but for those of us who’d rather operate Excel than operate on a human, it provides an incredible opportunity to blend the worlds of science and business and acts as a jumping point for a career in the business side of a scientific world.

CarolAnn Sudia is a Clinical Information Manager for Inpatient Medical Associates, an affiliate of Emergency Medical Associates, at Newton Medical Center, Newton, N.J.  Sudia received her undergraduate degree from Rutgers University, New Brunswick, N.J.

How to Tap Into Your Emotional Intelligence in the ED and at Home

By Marc Milano, MD, FACEP

Our last discussion left off defining the key aspects of emotional intelligence (EI). It should be clear that a strong supply of emotional intelligence can make one’s interactions better, one’s relationships stronger, and one’s quality of life higher.

I have long been fascinated by the lack of correlation between intellectual intelligence and success. In fact, many of the most intelligent people I have known have struggled in many ways, both personally and professionally. I’m sure that you have known these same individuals – brilliant but socially inept, highly intelligent but frequently unfulfilled.

During medical school and residency, I was lucky to have a great deal of emotional intelligence instilled in me by my teachers. I have had some good fortune in life as a result of those great influences. I don’t define my success financially, or by status, but rather by how others see me and relate to me, as well as by how I impact others. Many people have asked me how I have navigated my career and my life, as they would like to achieve a certain goal or reach a higher level. I always respond by telling them that it’s not raw intelligence that matters; rather, it’s emotional intelligence that has helped me most.

The Benefits of Using Emotional Intelligence

Several years ago, my wife and I decided that it was time to move to a larger home in a suburban setting to raise our growing family. We found the perfect place. One problem – it would have been a 90-minute commute from my job. As I looked around at possible places of employment that were closer to the new house, I found one – six miles away! I cold-called the director and explained the situation. He politely told me that the site was fully staffed and he was not looking for anyone. Thinking in an emotionally intelligent way, I told him that I would be glad to wait, but I could possibly help by covering parties, meetings, etc. This was music to his ears. He offered me an interview. During the interview, I explained my philosophy as an employee. I told him that every day when I walk into work, I’m thinking about how I will strive not to create headaches for my boss. Two months later, I had a full-time offer from him. He actually moved staffing around to accommodate me. I appealed to what mattered to him – covering difficult shifts and helping him avoid stress.

Intellectual intelligence can get you only so far in life. If you can’t use that intelligence in a way that helps you control yourself and interact positively with others, it may be largely wasted.

Emotional Intelligence touches every aspect of our lives. A few examples:*

  • Relationships: If you understand your emotions and how to manage them, you will be more effective in expressing your feelings. More importantly, you will understand how others are feeling. It will improve communication and help you build stronger relationships both professionally and personally.
  • Mental Health: Understanding and managing your emotions, and looking deeply into what causes you to respond a certain way will decrease your stress. Stress makes us vulnerable to anxiety and depression.
  • Physical Health: If you can’t successfully manage your stress levels, your health will suffer. Stress can raise your blood pressure, impair your immune system, increase the risk of heart disease and stroke and speed up aging.

Work Performance: Emotional Intelligence can assist you in smoothly navigating the social and political complexities at work. It can help you lead and motivate others and propel you toward excellence. Emotional Intelligence is now being viewed by many employers as being as important as your technical ability, and they may seek to assess your EQ as part of the hiring process.

How to Raise Your Emotional Intelligence

Remember: The brain receives all of its information via the senses, and if this information is highly stressful or emotional, primal forces take over and our ability to act is then reduced to fight, flight or freeze. If we keep our emotions in balance, we have access to a wider range of reactions and responses. This will result in better decisions and better outcomes. Stress impairs memory. Memory is linked to emotion. One must stay connected to the emotional brain while also tapping into the rational brain. By using both, you will have more choices in responding to an event, but you will factor emotional memory into the process. Doing so will help prevent you from making recurrent mistakes in the future.

To achieve Emotional Intelligence, you must work to reduce stress, remain focused, and stay connected to yourself and others. This is done by learning key skills. The first two relate to controlling and managing stress, and the last three skills greatly improve communication.**

  • The ability to quickly reduce stress in the moment in a variety of settings
  • The ability to recognize your emotions and keep them from overwhelming you
  • The ability to connect emotionally with others by using nonverbal communication
  • The ability to use humor and play to stay connected in challenging situations
  • The ability to resolve conflicts positively and with confidence
  • We will expand on these five skills in future discussions. Please continue to follow me on this journey. You can become a better you, and make your world a better place.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

* Daniel Goleman, Working with Emotional Intelligence
** Daniel Goleman, Emotional Intelligence

How to Better Understand the Needs of Your Patients

By Anthony J. Brutico, DO  78463795_15

One of the most important things we can do as emergency department providers is to always be aware of “the show.” Dr. Greg Henry describes the emergency department as “show business for ugly people.” And he’s right; sometimes the perception of the care we provide is just as important as the quality of the medicine.

There are two types of patients: those who use the emergency department as a place to get quick care and fast answers as a means of bypassing their primary care physician and those who believe they have a true emergency. Although the patients without a true emergency often are less ill than many of the other patients we see on regular basis, they also can be the most vocal and demanding.

They often are “well enough” to take careful notice of what we do, how we behave, and how long everything takes.  When a person is waiting for an ankle X-ray, they don’t have much else to do than to look and listen.  They hear gossip and staff complaints and can pay close attention to how our processes work.  They also usually have an expectation of their visit.  It is up to you as the provider to figure out what that expectation is–and to moderate it if you must, and to meet it if you can.

Is the patient with hematuria here for a urinalysis, or to see if he has cancer?  Is the person with a cough here because it’s hard for her to breathe, or to see if she has Enterovirus D68?  This may not always be apparent based on the complaint, but satisfaction for these patients can pivot on finding the answers to these questions. Patients often have, consciously or not, agendas.

Patients also like to see that they are getting something for their money.  Emergency department bills are often in the four to five figure price range.  And for that money, patients have expectations–including getting answers to specific questions.  Sure, you’ve determined the patient with foot pain for a week doesn’t have a fracture.  “Take ibuprofen, and follow up with your doctor.”  Realize a patient may have paid $3,000 for that “I could have done that myself” piece of medical advice.  Sure, our medical exam and opinion are highly valuable, but let’s face it, it’s not like they’re coming to see the Dalai Lama.  Remember the show – what else can you do?

Your goal is to have each patient leave the department feeling better than when he or she arrived. Ask what concerns the patient has.  Allay the fear; it’s very real, even if unrealistic. Ask if they need a work or school note.  Offer crutches and an ACE wrap.  Think, “What can we do?” instead of “There’s nothing to do.”  In my decade of treating patients in the emergency department, by far the most complaints have to do with:

  • Pain
  • Waiting
  • Getting what they came for

This by no means implies that you always should do what the patient wants.  I wouldn’t hand them a menu of tests and ask them what they would like.  I would, however, suggest that you always try to ascertain what specific concerns they have, address them, and do what you can to give the maximum attention to their issues, no matter how non-emergent they may be.  Patient satisfaction depends on it.

Anthony Brutico, DO, is the interim director of the emergency department at Newton Medical Center, Newton, N.J. Dr. Brutico received his medical degree from Lake Erie College of Osteopathic Medicine, and completed his residency at Memorial Hospital of York.

4 Qualities for Practicing Emotional Intelligence in Emergency Medicine

By Marc Milano, MD EQ

We meet new people and interact with those we already know in varied situations every day. And as emergency department providers, we encounter more new people in more diverse and stressful situations than most others do.

It should be clear that managing these interactions successfully will result in positive outcomes by creating the environment and experience of care that we want for our patients and colleagues.

A concept that helps to both define and inform us about good interactions is that of Emotional Intelligence. I define emotional intelligence as the ability to accurately, and in our case rapidly, discern what matters to another individual or group and use that information to provide mutual benefit.

Many authorities on the subject have suggested that emotional intelligence (EI or sometimes referred to as EQ – emotional quotient) is as important, if not more important, than IQ when it comes to success and happiness in life and work. I completely agree, as I have seen some highly intelligent people (high IQ) fail due to having a low EQ.

There are for basic qualities that embody emotional intelligence:

  1. Self Awareness – Recognizing your own emotions and how they affect your thoughts and behavior, knowing your strengths and weaknesses, and having self-confidence
  2. Self Management – The ability to control impulsive feelings and behaviors, manage your emotions in healthy ways, take initiative, follow through on commitments, and adapt to changing circumstances
  3. Social Awareness – The ability to understand the emotions, needs and concerns of other people, pick up on emotional cues, feel comfortable socially, and recognize the power dynamics in a group or organization. Empathy is a key here.
  4. Relationship Management – Recognizing how to develop and maintain good relationships, communicate clearly, inspire and influence others, work well in a team, and manage conflict

A new manager recently came to meet her new staff for the first time. She arrived late to the meeting. She began the introduction with a list of her accomplishments and then launched into her expectations of those she will supervise. She asked no questions of the staff and didn’t encourage their input or feedback. I can tell you for certain that after the meeting, the staff was not only intimidated, but worse yet, they were NOT engaged. That manager knew going into the meeting that this staff was facing great organizational change and uncertainty, coupled with being confronted with having to acclimate to a new leader.

How could she have done this better by applying emotional intelligence?

  1. She could have shown more respect for the group by coming 5 minutes early, not 5 minutes late. Having the forethought and consideration of how crucial this first interaction would be might have prevented that error.
  2. She could have done better by making a brief introduction and explaining why her prior experience would help her lead them to success.
  3. She could have, instead of laying down a set of expectations and changes without getting feedback, accomplished more by simply asking, “How can I help you achieve your goals?” or asking “What tools do you need from me to do an even better job?” Once she learned the needs of the group, she could use that knowledge to align the group with her goals and those of the organization.

This primer on emotional intelligence will serve as our first foray into a fascinating and important way of changing the way we interact with each other and the world around us. Please visit the blog in the future for additional posts on this topic. I encourage you to use the “Comment” feature to let me know your thoughts as well.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

My Experience Filming ‘Untold Stories of the ER’

By Anthony Brutico, DO Untold Stories of the Er

From the emergency room to television, it certainly was an interesting journey. As an emergency physician, I have a lot of patient stories. Some are sad, some will bring a smile to your face and others leave you wondering what the patient was thinking. “Untold Stories of the ER” is a TV show that highlights all of the stories that make you ask “what was the patient thinking?” I must say that I had never watched the show before, and I assumed, like most ED physicians, that we tend to shy away from medical drama because we live and breathe it every day.

The First Stages

I submitted three cases. They liked the cases I provided, and one in particular made the cut for the show. One of the show’s scouts called me and asked me to do a quick interview via Skype. The producers wanted to see how animated I was and to see if I had “radio face.”

After completing the interview, they turned my two-page case summary into a script for the show. The process took roughly two weeks to finish and I was mailed multiple versions of the script to check for medical appropriateness. To make the case entertaining for television, they spiced up the drama. The patients were younger and were trying to go on a second honeymoon, and what the patient took for his aliments also was altered. The main points of the case, however, remained the same, and the show wanted to stay true to the medicine of the case. Unfortunately the amount of “medicine” seen for a dissecting aortic aneurysm is limited from the ER perspective, but the case had some excitement, drama, and twists and turns that made it into the ninth season. You’ll have to watch the episode to see what happens, but here’s a preview – the husband initially was my patient, but then his wife also needed medical attention when she heard his diagnosis!

Filming in Canada

One of the perks of being chosen to appear on the show was they arranged all travel and flew me to Vancouver. They even worked around my schedule as they understand the demands of emergency medicine.

It was a great trip, and Vancouver was beautiful. I got to spend some time in the Gastown region of Vancouver, which has interesting restaurants, bars and shops. I didn’t appreciate the time change much, which I assume is due to the reality of emergency medicine work schedules.

The next day, we arrived onsite to see the set and practice a “table read” with the actors and director. The set is actually an abandoned psychiatric hospital that the show rents from the government. The 3rd floor is renovated to look like an ER, complete with fake computer terminals, phones, tracking board and other props. It’s a convincing set. The production crew films in different sections of the set and moves props around to make it look like a different hospital on each episode.

My director was Allan Harmon, who has worked on directing and assistant directing movies such as “Police Academy” and “American Pie Presents: The Book of Love.” He was a lot of fun to work with and was patient with physicians who never acted a day in their lives.

Lights, Camera, Action!

After the table read and the set walkthrough, it was back to the hotel for a night of good sleep and an early start at 7 a.m. for filming. We arrived and received a miniature version of the script for reference. Then it was off to hair and makeup and wardrobe. I brought my own scrubs, so they just pressed them, and the makeup girls prettied me up as much as they could, but they respected their limitations.

The shoot took 13 hours! We did scenes in an order different from the normal show progression, mainly due to the use of paid actors and set setup. We started in the CT scan room, which threw me off because as far as the script goes, we were starting on page 14. Each scene had required 2-5 takes, usually starting with a practice take and then filmed ones afterward. I remember them taking the script away from me because I wanted to bring it in the scene.

“Action!” the director yelled after the clack of the clapperboard in my face. And we were off. I had to be convincing, show a feel of urgency and concern, and never look at the camera. The hired medic and I were on hand to make sure the IVs, EKG leads and other small props looked authentic and were used properly. Makeup artists kept touching up my face and production assistants handed out water and pieces of candy bars to keep us hydrated and alert. It was definitely not a bad way to spend a day!

The Final Product

After it was all over, I got to see some of the takes that were recorded, got some food and headed back home. I got a few promo shots and as of the time I wrote this blog, I still haven’t seen the show! As far as some PR for the show, I also agreed to do “The Juice,” a morning TV talk show in New Jersey, to discuss some ER stories and mistake that ED patients make.

Interested in Being on the Show?

Untold Stories of the ER is a docudrama that airs on Discovery Fit Health and TLC. The show features real emergency doctors telling their most bizarre and puzzling case. All cases are based on actual events, but are highly dramatized. Barring exceptional cases where the patient themselves are involved, specifics regarding the hospital and the patient and the case are changed to protect everyone’s privacy, so consent from the hospital or the patients is not required.

To submit a case for consideration, email a short description of each story you’d like to share to Ann Hassett at

Anthony Brutico, DO, is the assistant director of the emergency department at Newton Medical Center, Newton, N.J. Dr. Brutico received his medical degree from Lake Erie College of Osteopathic Medicine, and completed his residency at Memorial Hospital of York.

The show airs August 29 on Discovery Fit Health at and Mid-October on TLC.

Mindful Solutions to Dealing with Patients

By Megan McGrane, PA  mcgrane
What do you know about mindfulness? Jon Kabat-Zinn, the father of the modern mindfulness practice, is a professor at the University of Massachusetts Medical School.  He describes mindfulness as the practice of being fully present in each moment, clear from distraction (1). Best put, mindfulness is paying attention “on purpose.” So why am I telling you this? And what does it have to do with your day-to-day in the emergency department?

Mindfulness is certainly not a concept broached by most medical training programs.  However, mindfulness is a practice that has been in my life for almost a decade and is integral in my interactions with patients in the emergency department.

I understand you may be thinking, “So, what does this mindfulness thing have to do with helping sick patients?” Let me tell you how this practice has everything to do with emergency medicine and how I believe it can revolutionize the way you interact with patients and families.

We have all been there. It is Monday at 5 p.m., a patient has been waiting for a few hours and now you are telling them they need a study that could take an additional two to three hours to complete. Maybe you have a patient in a hallway bed that is constantly being shuffled past and bumped into as stretchers round the bend in the busy part of the department.

Perhaps a patient’s blood draw was lost or misplaced and never made it to the lab. Frustration can ensue in any of these scenarios, and they are far from ideal for all parties involved. Let me give you a few techniques that use mindfulness to help you “pay attention on purpose” and ease your interaction with patients.


It is easy to take shallow, rapid breaths when we get angry, anxious or stressed. Often we are so unaware of this habit that it never even occurs to us.  In a frustrated moment, taking a deep breath in through your nose, holding for four counts, and then breathing out again is a great technique to slow everything down. I often do this when a patient is raising his voice with me or is becoming increasingly frustrated. It helps me to slow down and respond rather than react.

Listen. And then Pause

The empty spaces in conversations can be uncomfortable. That is, until you get used to them! Practice allowing a few seconds to pass before speaking or responding when a patient is voicing concerns; this practice can make a huge difference in how the conversation goes. It allows you time to process what has been said, take a breath, and then respond. It also gives patients a chance to know they are being heard. Sometimes they also may take this space to continue their thoughts if needed.  Allowing a pause in conversation tells patients you are taking time to think about what they said, not just give an instant reply.

Allow Room For the Patient to Ask Questions

Asking at the end of each interaction if the patient has any questions for you and then PAUSING (as in #2) gives the patient time to think of anything he or she might not understand about what you have said or what is happening during the visit. “What is a CT?” “How long do I have to take this medicine?” “What happens when you do this procedure?” This is a simple tip taught in the early stages of medical education that’s easy to skip over in the fast-paced emergency department.

Remember, It is Not About You

The ER is a familiar place to us as healthcare providers. We spend many days (and nights) in these halls. The dinging of monitors and overhead pages are like white noise in our day. However, for our patients it may be their first time in a hospital, not to mention a busy emergency department.  The patient or a family member may be experiencing a health crisis.  Often anger, frustration and irritation are multifaceted, and in the ER setting, they are inextricably linked to fear and pain. Using mindfulness and breathing strategies during a tough interaction can help remind you of this: it is not about you.

(1) Mindful Medical Practice: Just another fad? Can Fam Physician. Aug 2009; 55(8): 778–779.

Megan McGrane, PA,  is a full-time emergency department physician assistant at Saint Barnabas Medical Center in Livingston, N.J. She received a bachelor’s degree and a master’s degree in exercise physiology from the University of Pittsburgh and holds a second master’s degree from University of Medicine and Dentistry of New Jersey (UMDNJ/Rutgers), Piscataway, N.J. She is a member of the American Academy of Physician Assistants.

Quick Tips with Dr. Marc Milano

By Marc Milano, MD, FACEP Marc Milano, MD

Topic: Patient Satisfaction

As emergency physicians, we find each day different from the last. We are constantly faced with new patients, new illnesses and new challenges.

But regardless of the day, our focus always is on providing the best care for the patient. And while situations inevitably arise in which patients and their family or friends can become aggressive and outwardly frustrated, there are tips to remaining calm, alleviating frustrations and improving patient satisfaction.

Treat Everyone in the Room

In the emergency department, patients are often accompanied by friends and family members. This is especially true with the very young and the elderly. They need support during times of stress and uncertainty. You can use this fact to your advantage if you follow some simple guidelines.

  • When you enter the room, introduce yourself to the patient, then to their family members and friends.
  • Find out how the guests are related to the patient.
  • Address both the patient and the guests but keep your primary focus on the patient.
  • Don’t show that you are frustrated by questions from the group. Simply let them know that you will answer them when you are done evaluating the patient.
  • Show empathy toward caregivers and acknowledge their hard work in caring for a sick loved one.

When you’re done with the evaluation, explain your plan, how long you expect the visit to take (OVERESTIMATE!), and then ask the group if they understand. Doctors sometimes are afraid to ask “Do you have any questions,” as it might open the flood gates. However, I’m frequently shocked that the patient and companions have none. Another way of addressing is to ask the family “Does all of this information make sense to you? I know it can be overwhelming.”

You can then get them involved in the patient’s care plan by asking them to help the patient with things like drinking contrast, using the call bell for help or letting you know right away if something changes with the patient.

When you master these concepts and incorporate them routinely into your practice, you’ll rarely have to do “damage control” with an angry family member.

Keep Calm and Treat the Patient

It’s not uncommon to be confronted with an angry or aggressive patient in the emergency department. This is one of our biggest challenges, but handling it well can result in a good outcome, not to mention that it’s a really rewarding feeling to be able to turn a patient’s frown upside down! Be nice, and show compassion and a strong desire to make things right.

First, do not ignore the elephant in the room. If you know what the problem is, confront it directly. Saying things like “lower your voice” or “calm down” almost never help the situation – and in fact generally inflame it. I use phrases like, “I’m Dr. Milano, and I’m here to help understand the problem and do everything I can to fix it.” Sometimes this alone can turn the tide.

Often the anger is about waiting time, so I will offer something like, “I will do everything in my power to expedite your care, without compromising the quality of it.” You must then be prepared to deliver on that promise; however, as failing them again will just cause a re-escalation. Get on the phone with the lab/radiology, etc., and explain the situation. Let the other staff members know what’s happening and reassure them that you have already calmed the patient, but you need their help the keep things that way.

Occasionally, the anger or frustration is due to an unrealistic expectation (think MRI of the finger on a Saturday at 3 a.m.). This is an opportunity to educate the patient as to why a particular treatment or test is not warranted, and maybe explain how it might be harmful or could waste even more of their valuable time. Explain that you will treat the pain, stabilize the problem and provide appropriate referral and guidance to get the problem solved. I will say things like, “My main goal is to rule out the serious things, treat your pain, and then point you in the right direction.”

The ED is full of challenging medical situations. We are on the front lines of the war against death and disease every day. We occasionally make the seemingly miraculous happen. It seems like that should be enough, but our pledge is to treat the whole patient, the whole situation and always to give our best effort.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

Medical Research: All Evidence Isn’t Created Equally

By Phillip M. Stephens, DHSc, PA-C Image

The “research police.” It’s a title every medical provider needs to embrace these days. Our evidence-based medical system is increasingly overwhelmed with data, and if there’s anything worse than no data, it’s bad data.

We like to think that physicians are comfortable navigating medical literature, but in reality much is hidden from physicians or purposely buried. Mark Twain was right; there are three kinds of lies: lies, damned lies and statistics.

Research about research is a new phenomenon on the rise to combat the problem. The initial findings are startling.

In 2010, Harvard researchers examined the drug trials of five major classes of drugs measuring only if the trials were positive and who sponsored them. After reviewing more than 500 trials, they found 85 percent of industry studies produced positive results while only 50 percent of government-funded studies were positive.

In 2006, researchers examined 542 drug trials for psychiatric drugs during a 10-year period. Again, industry-sponsored studies favored their drug 78 percent of the time compared with 48 percent of independent trials.

Publication bias affects every field of science. Numerous groups have tried to reproduce studies published in academic journals, and when they fail to reproduce the results, the same journals refuse publication. Many are simply not interested in negative results.

In March 2012, Nature magazine did publish the results of a study in which researchers attempted to replicate the results of 53 studies in cancer research. They were able to reproduce only six.

The core issue that affects evidence-based medicine is that if you conduct 10 studies and physicians get to see only the five that favored the tested drug or treatment, that’s a problem. So what do we do?

While publication bias and selective referencing certainly exist, things slowly are changing. We now have open-access journals, which publish any human research trials whether positive or negative. There also is a push for registration of trials, although this hasn’t been aggressively enforced. Independent systematic reviews are a huge help and should be on the reading list of every medical provider. Specifically, the Cochrane Collaboration is a gold standard for evidence reviews since the 1980s. But there is more we can do.

Insist on Better Data

Whether interacting with the pharmaceutical industry or policymakers, insist that all of the data is provided for trials and that policies are developed to ensure good methodology from your local medical center, the Food and Drug Administration (FDA) or academic journals. Cochrane finally persuaded the maker of Tamiflu to release all its data after such a campaign, and Nature magazine subsequently published the Cochrane/Tamiflu controversy.

Teach Medical Students How to Spot Bad Evidence

Preparing the future generation of medical providers to defend themselves against industry marketing or flaky evidence is imperative. Critical thinking skills and research methodology should be a core measure of every medical curriculum.

Professional Organization Involvement

Every medical association is a needed watchdog concerning medical evidence through best practices committees and policy statements.

Critically Appraise Data Independently

It’s time consuming, but using Cochrane and other independent systematic reviews gets us only part way toward good data. Just as you have a system for reading an X-ray or interpreting a set of lab results, develop and teach a system of examining research beyond simply reading the abstract.

This involves:
Scanning the abstract

  • Identifying the research problem and its logical consistency
  • Examining the literature review for balanced critical analysis
  • Identifying the theoretical framework, research question and hypothesis
  • Reviewing the methods: the sample size and target population, and how the data was collected and analyzed.
  • Noting any ethical considerations and especially the methodology
  • Examining the procedures, variables, analysis and discussion
  • Noting the level of evidence
    • Remember: all evidence isn’t created equally. Level 5 evidence is considered “expert” opinion, which could mean three guys in a room thinking it’s a good idea to level 1a evidence, which is a “systematic review” with heterogeneity of variables.

The process of how we generate and interpret evidence-based data is currently not a predominant part of medical education, but in a world of evidence-based medicine, it should be. With an increasing level of evidence needed to feed evidence-based practice, faulty or misleading data is the next public health hazard. So when the news media announces one day that coffee is bad for you then the next day unashamedly says it’s good, question the evidence.

Phillip Stephens, DHSc, PA-C,is the associate practitioner site director for Emergency Medical Associates at Southeastern Regional Medical Center, Lumberton, N.C. He is adjunct faculty at A.T. Still University in Mesa, Ariz., where he teaches Research Methodology and has practiced as an emergency medicine physician assistant for 25 years.

How to Make the Most of Your Emergency Medicine Residency

By Shilpa Amin, MD, FACEPAmin

Dr. Seuss said it best: “Congratulations! Today is your day. You’re off to great places! You’re off and away! You have brains in your head. You have feet in your shoes, you can steer yourself in any direction you choose.”

You have worked extremely hard to get into your residency program, now make the most of these important years! Each year is a stepping stone to help you find the perfect job; you are the person who’ll decide where to go.

There is no manual to surviving residency, but there are a few pieces of advice I’d like to offer.

Intern Year: Learn the basics. There is no real substitute for understanding the fundamentals of teamwork, hard work and efficient work. When you are an intern, you are working the most shifts, doing many procedures and learning to absorb direction from many people: senior residents, attendings and consultants. Take this year to really understand how the ED functions, because the operations of the ED are unique. Use this year as a base for success for the rest of your residency. Ask lots of questions. Read when you have time. And most importantly, HAVE FUN.

Junior Year: Be a mentor and true teacher to the interns. Remember the saying: “See one, do one, teach one.” You will quickly learn procedures and how to care for critically ill patients. Strive to be a strong leader in your junior year. This year you will have more time to read and more time to network.

  • Start talking to the seniors who just graduated and see where and how they found their jobs.
  • Align yourself with colleagues who work in a setting that you see yourself in (academic, community, administrative).
  • Attend national conferences such as ACEP, AAEM or SAEM . Visit the booths and speak to other physicians about what they like most (and least) about their jobs.

Use this year to build a foundation for your job search. Toward the end of your junior year, begin researching different employment models, consider if you want to apply for a fellowship and where geographically you want to practice. Begin drafting an initial version of your CV and have your program director and other faculty review it to help you revise.

Senior Year: This is when the job search is in full effect. Use the summer months to network, learn what an independent contractor is – speak with your accountant or adviser to see if this is the right fit for you to help better understand the job market. Reach out to alumni from your program for more information. Your program director and chairman also are great resources if you’re looking for a job in a location that you’re not familiar with. Begin thinking about who you are going to ask to fill out your references for your applications. Finalize your CV and write a cover letter. Begin sending out emails to the EDs you are interested in applying to.

September and October of senior year is when most residents start interviewing. Give yourself enough time during each interview to spend time in the ED and shadow one of the doctors for a few hours. This will give you a real sense of how the ED functions as a system and works as a team. Interview at enough places to give yourself a broader understanding of the different work environments available to you and where you would fit best. I recommend researching and preparing questions in advance of each interview. Ask for a current copy of the schedule. Be sure to fully understand compensation and scheduling, how vacations work, and what type of malpractice coverage you will have.

In November and December, review all of the information obtained from your interviews.

  • Ask yourself where you will be most happy and have the most successful career.
  • Ask your mentors to sit with you and decipher the information and assess each site.
  • Review your contract and have a contract attorney review it for you as well, specifically examining restrictive covenants and any confusing language.
  • As a courtesy, let anyone who extended an offer that you don’t accept know where you decided to start your career.

“Today is your day! Your mountain is waiting. So, get on your way!”

Shilpa Amin-Shah, MD, FACEP, is a full-time attending emergency physician at Saint Barnabas Medical Center in Livingston, N.J. Dr. Amin is also the Director of the Physician Recruiting Team with Emergency Medical Associates, Parsippany, N.J. She received a bachelor’s degree from Rosemont College in Rosemont, Pa., and her medical degree from SUNY Downstate, Brooklyn, N.Y. She completed the Jacobi/Montefiore Emergency Medicine Residency Program at Albert Einstein College of Medicine and served as chief resident. She enjoys spending her free time cooking, traveling and trying new cuisines with her husband and two young children.

10 Tips for Success for Healthcare Newbies

By Kathleen Gardell Keyboard

As a child I longed to be a dancer. When deciding on a college major, I opted for dance. After an injury and many talks with my parents, I decided to switch majors and graduated with a degree in nutritional science with a dance minor. The path I’ve traveled to become a regional manager of our medical scribe program can be described as many things, but non-traditional would be the most accurate.

I spent a year traveling as a medical scribe for my company’s Site Support Team — a group of clinicians, scribes and support staff deployed to new client locations. Because I traveled to several different sites during this time, I became familiar with various ED sites and networked with a lot of medical directors, physicians, mid-levels and hospital administrators.

Through networking, I was presented with the opportunity to become a regional manager of the clinical information manger (CIM) department. This happened at the perfect time in my life. I was about to get married and knew that I soon wanted to put down roots and have a more regular schedule–although now I do have to admit that I do miss that random Tuesday or Thursday off that I would have with shift work.

I’m often asked by newly hired scribes what’s the best advice I can give them for succeeding in the position. It’s hard to narrow it down to one tip because I’ve learned a lot of lessons in the 10 years I’ve been in healthcare. Although my advice is not based on any proven theories, these are the top 10 things I’ve learned so far:

1. Know Yourself.

This sounds simple and straightforward enough. However, knowing yourself also means being able to recognize changes in yourself and then making informed decisions about your future based on those changes. For example, we are never the same person at the beginning of a journey that we are at the end. Being able to recognize what changed you and how will help you make better decisions about your future.

2. Pay Attention.

This means actively listen to your peers, your subordinates, and your superiors. Go into work every day with the intention of listening and learning. If you do, you’ll leave work every day having learned something new.

3. It is OK to Give Things Time.

This is even harder for those of us working in the fast-paced and hectic ED environment, but it’s important to remember that anything that’s worthwhile takes time. Mediocrity is often the result when things are done in haste; that which is worth doing at all is worth doing with time and consideration.

4. Plans are Made to be Broken.

Bumps in the road occur, and that’s OK. The real test will be to see how you react and recover from those inevitable bumps.

5. Don’t Worry, Be Happy

When you doubt your own ability, you are the only person standing in the way of your success. Self-doubt is very powerful, but it’s just a “feeling” that’s not based on any scientific facts or formulas. So silence any self-doubt you have before it consumes you. We are truly our toughest critics.

6. Set Goals Often.

If you want to succeed, you need to set goals. Without goals, you may lack focus and direction. If you set goals and have a plan for achieving them, it’ll be easier to correct any missteps along the way.

7. Happiness Takes Work.

Eleanor Roosevelt said, “Happiness is not a goal; it is a by-product,” and I have found this to be very true at work. If you demonstrate a great work ethic at a job you love, happiness will shine through in all you do.

8. Worry is Wasteful.

Worry about only the things that are in your control, the things that can be influenced and changed by your actions, not about the things that are beyond your capacity to direct or alter. This will save you many sleepless nights – and a few grey hairs, too.

9. No One Does Anything Alone.

True solo acts are rare. Most amazing feats in history were created and executed through the efforts of people who agreed to work together. So if you think that you can achieve all of your dreams on your own, you are mistaken. The more quickly you can admit that there will be a crowd of people cheering you on, opening doors, and working behind the scenes, the more quickly you will achieve success.

10. Passion Can Take You Where Talent Can’t.

I didn’t begin my scribe role as an outstanding talent among my peers, but I was passionate about doing the job well. I relied on my passion for hard work where my talent fell short, and this helped me tremendously. I’ve seen this to be the case as well with some of the best and brightest medical scribes that we’ve employed.

And let your passions lead you along some of those non-traditional paths; I still love to dance!

Kathleen Gardell is a Regional Manager for the Clinical Information Manager Department at Emergency Medical Associates, covering 10 emergency departments. She received a bachelor’s degree in nutritional sciences with a concentration in dietetics from Montclair (N.J.) State University. Prior to being promoted into her current role, Gardell was one of two medical scribes on Emergency Medical Associates’ CIM Staffing Support Team. She also has served as a medical scribe at Clara Maass Medical Center in Belleville, N.J., and Bayshore Community Hospital in Holmdel, N.J.


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